Brachial Plexus Injuries: Causes, Classifications & Symptom Guide

The brachial plexus is a complex network of nerves that acts as the main communication highway between your spinal cord and your arm, shoulder, and hand. When this network is stretched, compressed, or torn, it results in a brachial plexus injury. This can lead to significant pain, weakness, numbness, and functional limitations in the upper limb. Understanding the nature of these injuries is the first step toward effective treatment and recovery. This guide will explore the causes, types, symptoms, and rehabilitation options for brachial plexus injuries.

What Is a Brachial Plexus Injury?

A brachial plexus injury is damage to the web of nerves that sends movement and sensory signals from the spine to the shoulder, arm, and hand. The severity of these injuries can vary dramatically, ranging from a temporary "stinger" or "burner" commonly seen in sports, where nerves are only stretched, to severe, permanent paralysis caused by nerves being completely torn from the spinal cord. A clear understanding of the brachial plexus anatomy is crucial for accurate diagnosis, determining the injury's extent, and creating an effective treatment plan.

Anatomy and Function of the Brachial Plexus

The brachial plexus is formed by the nerve roots extending from the spinal cord at the C5, C6, C7, C8, and T1 levels in the neck. These roots combine to form trunks, divide into divisions, and then reorganise into cords before branching off into the major nerves of the arm. Each of these nerves is responsible for innervating specific muscles for movement and providing sensation to different areas of the skin, from the shoulder down to the fingertips.

How Injuries to the Brachial Plexus Disrupt Function

An injury anywhere along the brachial plexus pathway can disrupt the flow of motor and sensory signals. The location and severity of the damage directly determine brachial plexus injury symptoms. For example, an upper plexus injury might affect shoulder and elbow movement, while a lower plexus injury could impact hand function. Common impairments include muscle weakness, loss of grip strength, numbness or tingling, and poor coordination, all of which are linked to the specific classification of the injury.

Causes and Risk Factors of Brachial Plexus Injury

Brachial plexus injuries can stem from both traumatic events and non-traumatic conditions. They are most often caused by trauma that forces the head and shoulder apart, stretching or tearing the nerves. High-risk activities include contact sports, motorcycle accidents, and difficult childbirth, but other medical issues can also be responsible.

Traumatic Causes

The most frequent cause of brachial plexus injury in adults is direct trauma. This includes motor vehicle accidents, particularly those involving motorcycles, where the rider is thrown. Hard falls, industrial accidents, or violent impacts during contact sports like football or wrestling can create a powerful traction force on the shoulder. This sudden, forceful movement pulls the head away from the shoulder, overstretching the brachial plexus nerves and causing them to rupture or tear.

Obstetric Brachial Plexus Injury

Also known as OBPI, this type of injury occurs during childbirth. It happens when a baby's shoulders become stuck during delivery (shoulder dystocia), forcing the head and neck to be stretched to one side. This can damage the upper nerves of the plexus, leading to Erb’s palsy, or less commonly, damage the lower nerves, causing Klumpke’s palsy. Risk factors for OBPI include high birth weight, breech presentation, and prolonged or difficult labour.

Tumours, Inflammation, and Radiation

Less common brachial plexus injury causes can be just as serious. Tumours, whether cancerous or benign, can grow on or around the brachial plexus, compressing the nerves. Inflammation of the brachial plexus, known as Parsonage-Turner syndrome or brachial plexitis, can cause sudden, severe shoulder and arm pain followed by weakness. Furthermore, radiation therapy for cancers in the chest or neck can damage the brachial plexus nerves, leading to a progressive condition called radiation-induced brachial plexopathy.

Types and Classification of Brachial Plexus Injuries

To effectively diagnose and treat a brachial plexus injury, clinicians classify it based on the mechanism of injury, the type of nerve damage, and its anatomical location. These classification systems provide a framework for predicting prognosis and selecting the right treatment approach.

Leffert Classification System

Dr. Leffert’s system is widely used and categorises injuries based on their cause and location:

• Open: Caused by a laceration, such as from a knife or gunshot wound.
• Closed: Caused by stretching or compression (the most common type).
• Supraclavicular: Injury above the clavicle (collarbone), further divided into:
  
  • Preganglionic: The nerve root is torn from the spinal cord (avulsion).
  • Postganglionic: The nerve is damaged after it has exited the spinal cord.
  • Infraclavicular lesion: Injury below the clavicle.
• Radiation-Induced: Damage from radiation therapy.
• Obstetric: Birth-related injuries, including Erb's palsy (upper root injury causing a "waiter's tip" hand) and Klumpke's palsy (lower root injury).

Millesi Classification System

This system focuses on the precise neurological level of the injury, which is helpful for surgical planning:

• Supraganglionic/Preganglionic: An avulsion injury where the nerve root is pulled from the spinal cord. This is the most severe type with the poorest chance for spontaneous recovery.
• Infraganglionic/Postganglionic: The injury occurs to the nerve distal to the dorsal root ganglion. These injuries (ruptures, neuromas) have a better potential for recovery, often with surgical intervention.
• Trunk: Injury affecting one of the three trunks (upper, middle, or lower).
• Cord: Injury affecting one of the three cords (lateral, medial, or posterior).

Anatomical Location of Injury

The simplest classification is based on which part of the brachial plexus is affected:

• Upper Plexus Palsy (Erb’s Palsy): Involves the C5 and C6 nerve roots. This affects the shoulder and elbow muscles, making it difficult to lift the arm or bend the elbow.
• Lower Plexus Palsy (Klumpke’s Palsy): Involves the C8 and T1 nerve roots. This primarily affects the muscles of the hand and wrist.
• Total Plexus Lesions: Involve all five nerve roots (C5–T1), resulting in a completely flail and insensate arm.

Symptoms of a Brachial Plexus Injury

Symptoms of a brachial plexus injury depend entirely on which nerves are damaged and how severely they are injured. The effects are typically one-sided and can be grouped into motor (movement), sensory (feeling), and pain-related symptoms.

Motor Symptoms

Motor deficits are the most noticeable symptoms and can range from mild weakness to complete paralysis of the affected arm. This may include:

• Inability to lift the arm from the side or raise it above the head.
• Difficulty bending or straightening the elbow.
• A weak or non-existent grip.
• Paralysis of some or all of the muscles in the shoulder, arm, or hand.

Sensory Symptoms

Because the brachial plexus nerves carry sensory information, damage can lead to altered or lost sensation. Patients often describe:

• Numbness or a complete lack of feeling in parts of the arm or hand.
• A tingling or "pins-and-needles" sensation (paresthesia).
• An inability to feel temperature or pain, which can lead to unnoticed burns or cuts and delayed wound healing.

Brachial Plexus Pain Pattern

Pain is a common and often debilitating symptom. The brachial plexus pain pattern is typically neuropathic, meaning it originates from the damaged nerves themselves. This pain is often described as:

• A severe burning, crushing, or aching sensation.
• Sudden, shooting, or electric shock-like jolts of pain down the arm.
• Pain that originates in the neck or shoulder and radiates down to the hand. This pain may worsen with movement or even light touch.

Complications of Brachial Plexus Injuries

If a brachial plexus injury is severe or left untreated, it can lead to several long-term complications that affect quality of life.

• Stiff Joints: Lack of movement can cause the joints in the hand, elbow, and shoulder to become stiff (contractures), limiting the range of motion.
• Pain: Chronic neuropathic pain can persist long after the initial injury, becoming a significant source of distress.
• Numbness: Loss of sensation can be permanent, increasing the risk of further injury to the affected limb.
• Muscle Atrophy: Muscles that are no longer receiving nerve signals will weaken and shrink over time, making recovery more challenging.
• Permanent Disability: In cases of nerve avulsion or severe rupture, the injury can result in a permanent loss of function in the arm or hand.

Is a Brachial Plexus Injury a Disability?

Yes, a brachial plexus injury can be considered a disability, especially when it results in significant and long-term functional limitations. Whether it qualifies as a disability legally or for insurance purposes depends on the severity of the brachial plexus injury symptoms and their impact on a person's ability to perform daily activities and maintain employment. A partial disability might describe weakness or pain that limits certain tasks but allows for some function. A complete disability might be declared in cases of total plexus avulsion, where the arm has no movement or sensation.

Diagnosis and Evaluation of Brachial Plexus Injuries

An accurate diagnosis is critical for a positive outcome. The evaluation process typically begins with a detailed patient history - how the injury occurred - and a thorough clinical exam to assess muscle strength, reflexes, and sensation. To pinpoint the exact location and severity of the nerve damage, your doctor may order several tests:

• Imaging Studies: An MRI can visualise the brachial plexus nerves, while a CT Myelogram (a CT scan with contrast dye) can confirm if a nerve root has been avulsed from the spinal cord.
• Nerve Conduction Studies (NCS) and Electromyography (EMG): These tests measure the electrical activity in your nerves and muscles to determine if signals are being transmitted effectively.

Early and precise diagnosis is key to developing an appropriate treatment strategy and improving the chances of a meaningful recovery.

Treatment Options for Brachial Plexus Injury

Treatment for brachial plexus injuries is tailored to the type, severity, and timing of the injury. The goal is to restore as much function as possible to the affected arm.

Conservative Management

For milder injuries where the nerves are only stretched (neuropraxia), conservative management is often successful. This approach focuses on managing symptoms and giving the nerves time to heal on their own. It typically includes:

• Pain medication to control neuropathic pain.
• Immobilisation with a sling for a short period to protect the arm.
• Physical and occupational therapy to maintain joint mobility and prevent stiffness.

Surgical Intervention

Surgery is indicated for more severe injuries, such as nerve avulsions or ruptures, or when there is no sign of recovery after several months. The timing of surgery is critical, usually performed 3-6 months post-injury. Surgical options include:

• Nerve Grafts: A section of a healthy nerve from another part of the body is used to bridge the gap between two ends of a ruptured nerve.
• Nerve Transfers: A less important, healthy nerve is redirected to power a more crucial denervated muscle.
• Muscle Transplants: A healthy muscle and its nerve supply are moved to the arm to restore a key function, like bending the elbow.

Physiotherapy, Rehab and Long-term Recovery

Regardless of whether surgery is performed, rehabilitation is the cornerstone of recovery. Physiotherapy plays a vital role in restoring strength, retraining muscles, and improving mobility. A dedicated rehab program helps maximise functional outcomes. However, nerve tissue heals very slowly, about one inch per month, so recovery is a long process that can take months or even years. Consistent therapy is essential for success.

When to Seek Medical Help for a Brachial Plexus Injury

You should seek prompt medical evaluation if you experience any of the following, especially after an accident or injury:

• Severe pain in your neck, shoulder, or arm.
• Noticeable weakness or inability to move your arm, wrist, or hand.
• Complete numbness in any part of your arm.
• Any progressive weakness or sensory loss that worsens over time.
• Any suspected shoulder or neck trauma from an accident.

What to Expect During Recovery from Brachial Plexus Injury

Recovering from a brachial plexus injury is a marathon, not a sprint. It's crucial to set realistic expectations. Nerve regeneration is a slow and unpredictable process, and progress often comes in small increments. The recovery journey is typically divided into phases:

1. Acute Management: The Initial phase focuses on diagnosis, pain control, and preventing joint stiffness.
2. Strengthening & Re-education: As nerves begin to heal, therapy focuses on strengthening and reawakening muscles.
3. Functional Restoration: The final phase aims to integrate the recovered movement into meaningful daily activities. Patience and consistency with your therapy program are the most important factors for achieving the best possible outcome.

Begin Your Brachial Plexus Injury Recovery Journey with Physiotattva

At Physiotattva, our team specialises in the complex field of nerve and musculoskeletal rehabilitation. We understand that every brachial plexus injury is unique, which is why we develop individualised recovery plans based on a thorough assessment of your condition. Our approach focuses on restoring strength, improving mobility, and helping you regain the ability to perform daily functions.

We utilise advanced therapies like nerve mobilisation, targeted electrotherapy, and functional retraining to maximise your recovery. With continuous progress tracking and a supportive environment, we are committed to guiding you through every step of your journey. Don't let a brachial plexus injury define your limits.

Take the first step toward reclaiming your function. Contact Physiotattva today for a personalised assessment.

At Physiotattva physiotherapy clinics in Bangalore and Hyderabad, you receive personalised care tailored to your specific needs, ensuring effective results and comfort throughout your journey to recovery. 

Don’t wait to start your recovery! Get in touch with Physiotattva for more details! Contact us at +91 89510 47001.

FAQs

What causes a brachial plexus injury?

The most common cause is trauma, such as from a motorcycle accident, a fall, or a contact sport, that stretches the neck and shoulder apart. Other brachial plexus injury causes include difficult childbirth (obstetric injury), tumours, inflammation, or damage from radiation therapy.

What are the different types of brachial plexus injuries?

Injuries range from mild stretching (neuropraxia) to more severe ruptures (nerve is torn) and avulsions (nerve root is pulled from the spinal cord). They are also classified by location, such as upper plexus (Erb's palsy) or lower plexus (Klumpke's palsy) injuries.

In what time do most brachial plexus injuries resolve?

Recovery time varies greatly. Mild stretch injuries may resolve in a few weeks to months. Severe injuries, especially those requiring surgery, can take one to two years or longer to show significant improvement, and some deficits may be permanent.

How does physiotherapy treat brachial plexus injury?

Physiotherapy is crucial for recovery. It helps maintain a range of motion in stiff joints, uses specific exercises to strengthen reinnervating muscles, retrains movement patterns, manages pain, and helps patients adapt to functional limitations to regain independence.

Is a brachial plexus injury permanent?

It can be. While many milder injuries heal well, severe injuries like nerve avulsions often result in some degree of permanent weakness, sensory loss, or pain. Early diagnosis and appropriate treatment (including surgery and intensive therapy) can significantly improve the final outcome.