At the side of the neck on each side the nerves exit from the spinal areas at each level and join and separate in a complicated manner in what is anatomically called the brachial plexus. This nerve collection runs down from the neck to the armpit where it separates into the individual nerves of the arm. The plexus is well placed to be easily injured in knife wounds, bullet wounds, sudden traction (stretch) and direct blows. Because of the severity of the injury and limited recovery, a brachial plexus lesion can leave someone with a painful arm of very limited use.
Motorcycle injuries are the most common mechanism of brachial plexus injury, with severe traction occurring as the shoulder and head hit the ground, forcing the two structures apart and stretching the nerves severely. Wrenching the arm violently away from the body is a typical injury, with high speed car injury also providing many victims. Penetrating injuries from attacks with knives or guns or direct trauma from falls from a height or blunt objects can also give a brachial plexus injury.
Estimation of brachial plexus injuries is difficult to make and they are not common, occurring mostly in young men as does most trauma. Narakas, who treated over a thousand brachial plexus lesions, explained a rule of seven seventies about this kind of injury:
Traffic accidents made up 70% of injuries and 70% were on motorcycles, of which 70% had multiple injuries
70% of those with multiple injuries had injuries above the clavicle area, so-called supraclavicular injuries.
70% of supraclavicular injuries involved one nerve root being avulsed (pulled out of the spine) and 70% of those were lower nerve roots in the neck, 70% of which generate a chronic pain problem.
The brachial plexus nerves can be badly damaged by the wrenching injury which occurs when the arm and the neck are violently moved apart. The damage varies from a minor stretch injury to the complete rupture of the nerves away from the spinal cord. Ruptures which occur close to the spinal cord are more serious and have limited scope for reconstruction or recovery. They differ from ruptures which are located further from the spinal cord which can have a better recovery potential. If the arm is at the side at injury then the higher nerve roots (C5 and C6) are more likely to be injured, whilst if the arm is wrenched overhead in the injury the lower nerves (C8 and T1) are more likely injured.
A detailed examination of the arm may be necessary in a case of multiple injuries to ensure a brachial plexus lesion is not present. Typical symptoms are pain in the shoulder and neck, heaviness and weakness in the arm and abnormal sensations such as abnormal pain feelings or pins and needles. The shoulder can be very swollen and vascular injury from blood vessel traction should be suspected if pulses are absent or reduced. Medical examination of the reflexes, motor power and sensibility is performed to establish the nerves which have been injured and the degree of their injury. Testing for this can be difficult as nerve anatomy is variable and experience is necessary for interpretation.
Typical past management of brachial plexus injuries was conservative, the patient recovering from the injury and the doctors would monitor the changes in the muscle power and sensibility over 12-18 months. Once the time had elapsed the remaining restrictions were considered permanent although small changes could still occur with time. The arm was treated surgically to make it more useful as a tool or by amputating it if it was in the way. Typical management now is surgical, with early exploration of open injuries (e.g. knife wound) and direct repair of nerves. In blunt trauma this might be delayed.
During the long period waiting for any improvement, often up to 18 months, it is difficult to manage the problems such as development of chronic pain, arm swelling and maintenance of the normal ranges of the joints. Physiotherapists are closely involved in the maintaining of healthy joints and the strengthening of recovering muscles. The restoration of functional muscle strength by surgical intervention is more predictable in younger people. - 14130
Motorcycle injuries are the most common mechanism of brachial plexus injury, with severe traction occurring as the shoulder and head hit the ground, forcing the two structures apart and stretching the nerves severely. Wrenching the arm violently away from the body is a typical injury, with high speed car injury also providing many victims. Penetrating injuries from attacks with knives or guns or direct trauma from falls from a height or blunt objects can also give a brachial plexus injury.
Estimation of brachial plexus injuries is difficult to make and they are not common, occurring mostly in young men as does most trauma. Narakas, who treated over a thousand brachial plexus lesions, explained a rule of seven seventies about this kind of injury:
Traffic accidents made up 70% of injuries and 70% were on motorcycles, of which 70% had multiple injuries
70% of those with multiple injuries had injuries above the clavicle area, so-called supraclavicular injuries.
70% of supraclavicular injuries involved one nerve root being avulsed (pulled out of the spine) and 70% of those were lower nerve roots in the neck, 70% of which generate a chronic pain problem.
The brachial plexus nerves can be badly damaged by the wrenching injury which occurs when the arm and the neck are violently moved apart. The damage varies from a minor stretch injury to the complete rupture of the nerves away from the spinal cord. Ruptures which occur close to the spinal cord are more serious and have limited scope for reconstruction or recovery. They differ from ruptures which are located further from the spinal cord which can have a better recovery potential. If the arm is at the side at injury then the higher nerve roots (C5 and C6) are more likely to be injured, whilst if the arm is wrenched overhead in the injury the lower nerves (C8 and T1) are more likely injured.
A detailed examination of the arm may be necessary in a case of multiple injuries to ensure a brachial plexus lesion is not present. Typical symptoms are pain in the shoulder and neck, heaviness and weakness in the arm and abnormal sensations such as abnormal pain feelings or pins and needles. The shoulder can be very swollen and vascular injury from blood vessel traction should be suspected if pulses are absent or reduced. Medical examination of the reflexes, motor power and sensibility is performed to establish the nerves which have been injured and the degree of their injury. Testing for this can be difficult as nerve anatomy is variable and experience is necessary for interpretation.
Typical past management of brachial plexus injuries was conservative, the patient recovering from the injury and the doctors would monitor the changes in the muscle power and sensibility over 12-18 months. Once the time had elapsed the remaining restrictions were considered permanent although small changes could still occur with time. The arm was treated surgically to make it more useful as a tool or by amputating it if it was in the way. Typical management now is surgical, with early exploration of open injuries (e.g. knife wound) and direct repair of nerves. In blunt trauma this might be delayed.
During the long period waiting for any improvement, often up to 18 months, it is difficult to manage the problems such as development of chronic pain, arm swelling and maintenance of the normal ranges of the joints. Physiotherapists are closely involved in the maintaining of healthy joints and the strengthening of recovering muscles. The restoration of functional muscle strength by surgical intervention is more predictable in younger people. - 14130
About the Author:
Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for Physiotherapists in Bournemouth visit his website.
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