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Brachial Plexus Injury

101 citationsUpdated Oct 2026

Overview

Brachial plexus injuries are more prevalent than generally appreciated, yet only a minority of affected patients are referred for specialist evaluation and treatment [1]. The term "birth brachial plexus injury" is advocated because the pathophysiology relates directly to the birthing process [12]. These conditions require a multidisciplinary approach and a broad range of treatment modalities to optimize function in the growing child [2]. The changing pattern of pathology and glenohumeral joint dysplasia necessitates varied treatment strategies [2]. In cases of complete lesions, preoperative clinical evaluation coupled with MRI could allow avoiding the morbidity of cervical exploration [3]. For traumatic injuries, reconstruction of elbow extension is worthwhile and should be viewed as a priority, particularly if hand function is preserved [18]. Patients with functional deficits resulting 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 [19].

The window of opportunity for successful primary neurosurgical treatment of infants with an upper brachial plexus birth injury extends past 3 to 8 months [11]. A better chance of recovery can be expected for patients with closed injuries when brachial plexus exploration is done within 3 months of injury [6]. Nerve transfers are replacing other techniques as the gold standard for brachial plexus and other proximal peripheral nerve injuries [36]. These transfers offer functional outcomes surpassing those obtained from traditional nerve repair or tendon transfers [36]. Nerve transfers have broadened reconstructive options and delivered more reliable results for some patterns of injury [55], providing a particular improvement in outcome for reconstruction of the paralysed shoulder in traumatic brachial plexus injury [55]. Distal nerve transfers are the preferred option for the reconstruction of elbow flexion in upper-type brachial plexus injuries, where possible [57].

Different procedures for the treatment of obstetrical brachial plexus palsy are complementary and allow a good recovery of function of a nondominant limb in 75% of cases [7]. In the delayed presentation of brachial plexus birth injury, brachial plexus reconstruction results in good functional recovery of elbow flexion and shoulder external rotation [9], but only modest functional recovery of finger flexion and wrist extension [9]. Surgical reconstruction can improve both form and function in the limb for properly selected and evaluated children with pronation contractures of the forearm secondary to obstetric brachial plexus injury [59]. Early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants [52]. Parents should not be discouraged from treatment of their child’s brachial plexus injury due to fear of surgical complications [37].

Anatomy & Pathophysiology

Injury Mechanisms and Etiology

Brachial plexus injuries are far more common than generally appreciated, though only a minority of patients receive specialist evaluation [1]. Obstetrical brachial plexus injury (BPBI) occurs in at least 1.5 of every 1000 live births and is most frequently caused by traction on the plexus during difficult childbirth, which injures the C5-C6 nerve roots and weakens or paralyzes the shoulder and elbow [129]. The aetiology of obstetrical injury is confirmed by operative findings of a traction lesion [28]. In cephalic presentations, large babies (>4 kg) requiring forceps or suction sustain traction of the upper roots, most commonly C5 and C6, and occasionally C7 [28]. In breech presentations, small babies sustain traction injuries [28]. While spontaneous neurological recovery occurs, 20%-30% of BPBI patients suffer residual deficits in nerve and muscle function [129]. Up to 33% sustain permanent postural and osseous deformities [129].

Traumatic brachial plexus injuries result from traction forces causing nerve ruptures or root avulsions, generated by direct or indirect trauma to the shoulder girdle [128]. Shoulder dislocations with motor deficits are orthopedic emergencies requiring expedient reduction [45]. Iatrogenic nerve injuries remain an inherent risk in shoulder surgery due to positioning and specific surgical steps [51]. Specifically, shoulder abduction >70°, combined external rotation >60° with extension >50°, and downward forces on the humeral shaft may cause brachial plexopathy [136].

Pathophysiology and Secondary Deformities

The primary goal in brachial plexus injury reconstruction is achieving a stable and dynamic shoulder girdle [20]. The medial rotation contracture of the shoulder in obstetric brachial plexus palsy is a complex progressive deformity [151]. Shoulder muscle imbalance alone causes neither subscapularis shortening nor internal rotation contracture [101]. Rodent models of BPBI exhibit impaired longitudinal muscle growth, glenohumeral deformation, and shoulder internal rotation and elbow flexion contracture [129]. Rat models demonstrate restricted longitudinal muscle growth of the pectoralis major, spinal deltoid, and subscapularis following postganglionic injury [129]. Following preganglionic injury, restricted longitudinal muscle growth is observed in the spinal deltoid, biceps long head, biceps short head, supraspinatus, and teres major [129].

More severe shoulder and elbow contractures present with nerve root ruptures distal to the dorsal root ganglion (postganglionic), whereas avulsion injuries proximal to the dorsal root ganglion (preganglionic) typically present as paralysis without contracture [129]. Postganglionic injuries demonstrate greater spontaneous recovery and amenability to surgical repair compared with preganglionic injuries [129]. The spatial orientation of the coracoid process differs significantly between affected and contralateral shoulders in obstetric brachial plexus injury and is highly correlated with glenohumeral deformity [107]. Shoulder internal/external rotation in abduction and adduction is not interchangeable in children with brachial plexus birth injury [108].

Tendon transfers reorient the arc of motion into more external rotation and abduction rather than increasing glenohumeral motion, highlighting the importance of scapulothoracic function for outcome determination [121]. Tendon transfers improve overall shoulder motion but do not reduce humeral head subluxation or enhance glenohumeral joint realignment in children with residual brachial plexus birth palsy [142]. Subscapularis muscle release performed before the 2nd year results in a balancing of the shoulder in over 50% of cases and prevents humeral head deformation [123]. Subscapularis release is not always required to overcome internal rotation contracture, and secondary glenohumeral changes might be prevented with this approach [135]. Abduction is maintained over the long-term after latissimus dorsi transfer, but external rotation and internal rotation deteriorate, leading to functional impairment [149]. The study reports a significant long-term decrease in shoulder abduction despite maintenance of external rotation and improvement in elbow extension following low rotation humeral osteotomy [126]. 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 [61]. 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 [56].

Neurological and Sensory Pathophysiology

Pain intensity correlates significantly with the number of roots avulsed prior to surgery in severe brachial plexus avulsion injuries [138]. Surgical repairs for brachial plexus avulsion injuries are associated with pain relief [138]. Sensory recovery to thermal stimuli was observed mainly in the C5 dermatome following brachial plexus avulsion injury and surgical repairs [138]. Allodynia to mechanical and thermal stimuli was observed in the border zone of affected and unaffected dermatomes in 18% of patients assessed early (<6 months) and 37% of patients at later stages [138]. Pain and sensations referred to the original source of afferents occurred at a later stage (46 months) in 12% of patients and were related to nerve regeneration [138]. 'Wrong-way' referred sensations (e.g. down the affected arm while shaving or drinking cold fluids) were reported by 44% of patients and often occurred early, suggesting CNS plasticity [138].

Relevant Shoulder Anatomy

The brachial plexus and axillary artery are anterior to the coracoid process of the scapula and humeral head [66]. Nerves innervating muscles around the shoulder include the axillary, suprascapular, subscapular, and musculocutaneous nerves [66]. The brachial plexus and axillary artery can be injured with anterior shoulder dislocations [66]. Due to its close proximity to the proximal humerus, the brachial plexus is prone to injury when the proximal humerus is injured in fractures or dislocations, or during traction [72]. In the shoulder girdle, anatomic considerations are amplified by the proximity of the brachial plexus and major vessels of the upper extremity to the humerus, scapula, and chest wall [70]. Both the brachial plexus and the axillary vessels are contained within their own sheaths [70]. Primary tumors of the brachial plexus (malignant peripheral nerve sheath tumors) usually manifest on clinical examination as a brachial plexus nerve deficit [70].

The axillary nerve is a terminal branch coming off the posterior cord of the brachial plexus just proximal to the coracoid process [71]. It passes beneath the conjoined tendon anterior to the subscapularis 3 to 5 mm medial to the musculotendinous junction and then adjacent to the inferior capsule before entering the quadrilateral space posteriorly [71]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [72]. It splits into the anterior and posterior branches within the quadrangular space [71]. The anterior and middle deltoid muscle receives sole innervation from the anterior branch of the axillary nerve [71]. Posterior deltoid muscle innervation varies, with supply only from the anterior branch in 2.3% of cases, from the posterior branch in 8.5%, and from both branches in 89.1% [71]. The posterior branch of the axillary nerve branches to supply the teres minor muscle and then terminates as the superior lateral brachial cutaneous nerve [71].

The glenohumeral joint depends on static and dynamic stabilizers for movement and stability, especially the rotator cuff [77]. The rotator cuff fixes the fulcrum of the upper extremity against which the deltoid can contract and elevate the humerus [77]. The rotator cuff must act simultaneously and synergistically with the deltoid muscle for normal function [77]. The glenoid is a convex structure of shallow depth shaped like an inverted pear [65]. The acromion, the coracoacromial ligament, and the coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure that imparts stability to the shoulder girdle [65]. The rotator cuff, subacromial bursa, and subdeltoid bursa pass underneath the coracoacromial arch [65].

The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [65]. The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [65]. The anterior humeral circumflex artery (AHCA) arises from the axillary artery at the inferior border of the subscapularis and provides vascular inflow to the humeral head by way of its terminal anterolateral branch known as the artery of Laing (also known as the arcuate artery) [65]. The ascending branch of the AHCA courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and greater tuberosity [65]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [65]. Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [65]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [68]. It travels proximally in the lateral aspect of the intertubercular groove and the terminal intraosseous portion of the artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [68]. 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 [66]. More recent quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [72]. This vascular distribution explains the exceedingly low rate of osteonecrosis associated with anterior shoulder dislocations [72].

The glenohumeral joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic [78]. The bony anatomy contributes little to stability and has been compared with a golf ball on a tee [78]. The glenoid is encircled by the labrum, composed of dense fibrocartilaginous tissue, which increases the depth of the socket by 50% around the humeral head and increases stability [78]. The glenoid articular surface and the labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [78]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [78].

The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction and is the primary stabilizer to anterior and posterior stress in the same position [78]. The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction [78]. The inferior glenohumeral ligament is composed of an anterior band that is quite thick, a posterior band that is less thick and distinct, and a thinner intervening axillary pouch, creating a hammock-type sling [78]. With external rotation, the hammock slides anteriorly and superiorly, the anterior band tightens, and the posterior band fans out [78]. With internal rotation, the opposite occurs in the inferior glenohumeral ligament complex [78]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [78].

The extrinsic muscles primarily control movement of the scapula and include the rhomboids, levator scapulae, trapezius, and serratus anterior [78]. The intrinsic muscles control the glenohumeral joint and include the rotator cuff muscles (subscapularis, supraspinatus, infraspinatus, and teres minor), the deltoid, the pectoralis major, the teres major, the latissimus dorsi, and the biceps brachii [78]. The most important force couple involves the subscapularis and posterior rotator cuff, providing a compressive force that centers the humeral head in the glenoid cavity [78]. The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [78]. The infraspinatus and teres minor fuse near their musculotendinous junctions [78]. The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [78]. The roof of this sheath consists of a portion of the supraspinatus tendon, and a sheet of the subscapularis tendon forms the floor [78]. The coracohumeral ligament is a thick band of fibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons [78]. The coracohumeral ligament is deep to the tendinous insertion of the cuff and blends with the capsule and supraspinatus tendon to form part of the roof of the biceps sheath [78].

The rotator cuff is a sheet of conjoined tendons closely applied over the shoulder capsule and inserting mainly into the greater tuberosity of the humerus, with subscapularis inserted into the lesser tuberosity [73]. The cuff is made up of subscapularis in front, supraspinatus above and infraspinatus and teres minor behind [73]. Arching over the cuff is a fibro-osseous canopy – the coracoacromial arch – formed by the acromion process posterosuperiorly, the coracoid process anteriorly and the coracoacromial ligament joining them [73]. Separating the tendons from the arch, and allowing them to glide, is the subacromial bursa [73].

The scapula is attached to the axial skeleton by the clavicle, or, more specifically, by the acromioclavicular (AC) and sternoclavicular (SC) joints [67]. The scapula is enveloped in multiple layers of muscles and separated from the chest wall by thin gliding fibro-fatty tissue, allowing its smooth excursion over the chest wall [67]. The basic part of the scapula is the body, which is triangular when viewed anteroposteriorly, with its base situated superiorly and its apex inferiorly [67]. The glenoid is connected with the flat body of the scapula by the scapular neck [67]. The hook-shaped coracoid process curves forwards from the superior surface of the scapular neck [67]. On the posterior surface of the scapular body, there arises a prominent plate of bone, the scapular spine, ending in a flattened bony process, the acromion, which curves forwards [67]. The highest concentration of bony mass in the scapula is in the glenoid, the scapular neck (including the base of the coracoid process), and the lateral border of the scapular body [67]. Extending between the glenoid and the scapular body are two bony pillars that transmit compressive forces from the glenoid fossa [67]. The lateral pillar connects the inferior border of the glenoid with the inferior angle [67]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [67]. The two pillars, connected by a markedly thinner medial border of the scapular body, form the basic load-bearing structure of the scapular body [6

Classification

Brachial plexus injuries are more common than generally appreciated, yet only a minority of patients are referred for specialist evaluation and treatment [1]. The aetiology in obstetric cases is obstetrical trauma, confirmed by operative findings of a traction lesion of the plexus [28]. In breech presentation, small babies sustain traction of the lower roots of the brachial plexus [28]. 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 [2].

Narakas: Narakas’ classification introduced a four-group system based on patterns of neurologic involvement for brachial plexus birth injuries [58]. * Group 1: Upper Trunk palsy, consisting of Sunderland grade 1–2 injuries to C5 and/or C6 [58]. * Group 2: Extended Upper Trunk palsy, consisting of Sunderland grade 2–3 injuries to C5–6 and grade 1–2 injuries to C7 [58]. * Group 3: Flail extremity, defined as total paralysis (C5–T1) [58]. * Group 4: Total paralysis with Horner’s syndrome (C5–T1 + Horner’s) [58].

This classification is frequently misquoted, with inaccuracies traced to Birch and perpetuated by subsequent studies, particularly regarding the distinction between groups 3 and 4 [58]. Misinterpretations of Narakas’ classification have inflated spontaneous recovery rates and obscured the nuances of original observations of nonoperatively treated children [58]. In Narakas’ series, 93% of nonoperatively treated patients with Group 1 injuries achieved full spontaneous recovery [58].

Chuang: The Chuang classification defines the level of injury as follows [134]: * Level 1: Preganglionic root (i.e., root and rootlet) [134]. * Level 2: Postganglionic spinal nerve [134]. * Level 3: Pre- and retro-clavicular trunks and divisions [134]. * Level 4: InfrACLAVICULAR cords and terminal branches [134].

Other Considerations: A new type of brachial plexus lesion, the intermediate palsy, has been defined to be added to the classical types, involving predominantly C7 with variable involvement of the upper or lower plexus [53]. Various classifications of the level of brachial plexus injury have been proposed, including Millesi, Alnot, Terzis, and Chuang [134]. The EFFUL classification system is an objective method of measuring residual function before and after treatment in patients with peripheral nerve injuries [50]. Classification systems for secondary shoulder deformities in obstetric brachial plexus palsy cannot be used to evaluate the outcome of treatment or to compare the pre- and postoperative status of the shoulder [60]. Because recovery from brachial plexus neurolysis or repair is always incomplete even in children, the constellation of sensory and motor deficits varies greatly from patient to patient and resists an easy classification into patterns by nerve root level [34]. The classification of brachial plexus injury severity based on Dumitru's and Wilbourn's scale was applied to seven groups of patients in a tertiary care hospital study [105]. In a study of 111 patients, 81% (35/43) of arms with pan root involvement and 73% (16/22) of arms with pan plexus involvement were classified as 'severe' in nature [105]. There was no significant association between the etiologies and the anatomical levels of brachial plexus injuries (P = 0.21) [105]. 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 [125].

Clinical Presentation

General Presentation and Diagnosis

The diagnosis of a brachial plexus lesion must be made early and managed in a timely manner [42]. In multitrauma situations, the injury may be overlooked or neglected while other associated injuries are evaluated [42, 94]. In lesser magnitude injuries resulting in shoulder fractures or dislocations, neurologic examination of the shoulder, elbow, and hand may not be performed satisfactorily [42]. Nerve injury may be misinterpreted as pain from the skeletal injury or assumed to be rotator cuff pathology [42]. Consequently, diagnosis is often delayed, resulting in mistreatment [42, 94]. Neurologic injury must not be assumed to be a neuropraxia or reversible condition without signs of immediate improvement [42]. Patients with severe injuries, such as several root avulsions, must not be followed indefinitely for spontaneous recovery or told that no operative intervention is available [42].

The diagnosis is suspected from a good history supported by physical examination and confirmed by electrodiagnostic or imaging studies [94]. The mechanism of injury, particularly the position of the neck and arm in relation to the body during trauma, needs to be evaluated [94]. A thorough primary and secondary assessment should identify concomitant injuries to the head, chest, vessels, long bones, pelvis, and spine [94]. Ideally, the diagnosis is made in the emergency department [94]. Additional diagnostic information includes whether the injury is complete or incomplete, whether it involves the supraclavicular or infraclavicular region, and whether it is a preganglionic or postganglionic injury [94]. These localizations are helpful in planning treatment and predicting prognosis [94]. The diagnosis and definition of severity are made by a combination of history, physical examination, imaging, electrodiagnostic studies, operative exploration, and intraoperative electrophysiology [42]. The lesion should be localized to the supraclavicular or infraclavicular region [42].

Specific Injury Patterns and Prognosis

Most cases of brachial plexus injury after shoulder dislocation have a good prognosis for recovery, except for intrinsic muscles of the hand [8]. Patients with functional deficits resulting 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 [19]. Glenohumeral abduction contracture is a very common finding in patients with upper neonatal brachial plexus injury, affecting approximately three-quarters of these patients [43]. The frequency of glenohumeral abduction contracture decreases substantially in complete palsies [43]. Most obstetric brachial plexus injury patients with isolated absent or slowly recovering shoulder movements recover at least 90 degrees of abduction [17]. 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 [22]. Serious brachial plexus injury after median sternotomy is uncommon, with an incidence of 0.2% in this series [35]. The potential for delayed nerve injury following a fracture needs to be appreciated to prevent delays in diagnosis and treatment [47]. Systematic physical examination and knowledge of anatomy are critical for prevention and recognition of iatrogenic nerve injuries in shoulder surgery [51].

Diagnostic Modalities

Appropriate treatment depends on determining whether nerve root avulsion has occurred [24]. The most accurate assessment of the nerve rootlets is by direct observation [24]. A laminectomy only for diagnostic purposes alone is unjustifiably invasive [24]. Surgical exploration of the brachial plexus with visualization of the nerve roots and recording of SEP from each nerve root is a reasonable compromise [24]. The absence of SEP does not always mean that a pre-ganglionic root avulsion has occurred, but it may reflect an intra-foraminal nerve rupture [24]. Repair of intra-foraminal lesions is not technically feasible at this time [24]. The management of intra-foraminal lesions is identical to that of pre-ganglionic avulsion [24].

The place of pre-operative myelography in traumatic brachial plexus injury is controversial [24]. An Al lesion may or may not indicate an avulsion [24]. Al lesions are most common at the C5 and C6 level [24]. Myelography is least helpful where it is most needed [24]. CT myelography is superior to routine myelography in visualizing the relationship between the nerve rootlets and the spinal cord [24]. Routine myelography can create images only in the coronal and sagittal planes [24]. Plain radiographs of the chest might reveal an elevated diaphragm from a phrenic nerve injury [94]. Radiographs of the cervical spine and other bones might demonstrate fractures [94]. Angiography should be performed if vascular injury is suspected, especially when an acute brachial plexus injury is present in conjunction with an expanding hematoma, first-rib fracture, widened mediastinum, or upper limb pulse abnormality [94].

Electrodiagnostic studies are most useful about 3 weeks after the injury [94]. Electrodiagnostic studies can further localize the lesion and assess the degree of neural involvement [94]. CT-myelography should be performed when a supraclavicular lesion has been diagnosed and a preganglionic injury is being considered [94]. Shoulder MRI has been used to assess patients with nerve injuries, particularly those associated with shoulder dislocations and proximal humerus fractures to ensure rotator cuff integrity [94]. Shoulder MRI has been used in isolated suprascapular nerve lesions to identify ganglia [94]. MRI of the brachial plexus is rapidly improving, but it has not yet been found to be as helpful as CT-myelography in identifying root avulsions [94].

Features that can suggest a preganglionic injury include: * Deafferentation pain [94] * Horner syndrome (miosis, ptosis, anhidrosis, and enophthalmos) [94] * Weak rhomboids or serratus anterior muscles [94] * Absence of Tinel’s sign in the neck on physical examination [94] * Electrical studies showing fibrillations in the paraspinal muscles or rhomboids [94] * Preserved sensory nerve action potentials in an anesthetic hand with absent motor nerve action potentials [94] * An elevated hemidiaphragm or associated cervical fractures on radiographs [94] * Pseudomeningoceles or absent nerve rootlets on myelography [94]

Targeted fascicular biopsy of the brachial plexus is an efficient diagnostic procedure [99]. In highly selected cases, targeted fascicular biopsy of the brachial plexus can be offered as the initial procedure over distal cutaneous nerve biopsy [99].

Initial Management and Observation

For closed injuries, patients are typically observed for spontaneous improvement over the first several months [94]. It is important to obtain a baseline examination and then monitor clinical and electrophysiologic examinations serially for improvement [94]. Patients who demonstrate improvement within this time frame have sustained a neurapraxic injury [94]. It is difficult to preoperatively determine which axonotmetic lesions (those of Sunderland grades II to IV) will recover spontaneously despite their differing prognoses [94]. Grade II axonotmetic lesions are associated with good spontaneous recovery [94]. Grade IV axonotmetic lesions have a poor prognosis [94].

Patients should receive physical therapy for range of motion to prevent soft tissue contractures and to strengthen working muscles [94]. Neuropathic pain should be managed by a specialist, especially when it is refractory to first-line medications [94]. Deafferentation pain is often refractory to first-line medications [94]. Pain in avulsion lesions of the brachial plexus represents the most significant impediment to rehabilitation [96]. A better chance of recovery can be expected for patients with closed injuries when brachial plexus explorations is done within 3 months of injury [6].

Investigations

Clinical Assessment and Electrophysiology

The combination of clinical examination, routine electromyography, and paraspinal electromyographic studies predicts the site of the lesion in 80% of patients with intra- or extraforaminal brachial plexus injury [154]. In patients with a combination type of brachial plexus lesion, this same diagnostic triad predicts the site of the lesion in 67% of cases [154]. The absence of somatosensory evoked potentials (SEP) does not always indicate pre-ganglionic root avulsion, as it may reflect an intra-foraminal nerve rupture [24]. Surgical exploration of the brachial plexus with visualization of the nerve roots and recording of SEP from each nerve root serves as a reasonable compromise for assessing nerve rootlets [24]. While direct observation is the most accurate assessment of the nerve rootlets, a laminectomy performed solely for diagnostic purposes is considered unjustifiably invasive [24].

Imaging

MRI: In cases of complete brachial plexus lesions, preoperative clinical evaluation coupled with MRI can allow for avoiding the morbidity of cervical exploration [3]. MRI should typically be performed before making a treatment decision to examine the brachial plexus for any discontinuity or kinking [106].

Myelography: Myelographic findings A3, D, and M indicate lesions in Zone I or II(+ I), suggesting that if all roots are thus affected, exploration of the brachial plexus may not be necessary [147]. An Al lesion on myelography may or may not indicate an avulsion, as 43.8% of Al lesions were pre-ganglionic and 52.8% were post-ganglionic or intact [24]. Al lesions on myelography are most common at the C5 and C6 level [24].

Associated Pathology and Complications

Combined subclavian artery and brachial plexus injury as a result of blunt trauma is a rare occurrence that results in devastating functional disability of the upper limb [22]. Prompt release of 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 [23]. Neonatal brachial plexus injuries result in structural changes in the affected bone, including reduced trabecular bone density and cartilage thinning [153]. The frequency of glenohumeral abduction contracture decreases substantially in patients with complete brachial plexus palsies [43].

Treatment

Non-Operative

Conservative management is not a standalone curative strategy for traumatic brachial plexus injuries, as surgical intervention is indicated only for patients without the likelihood of spontaneous or further recovery [89]. In obstetric brachial plexus injury, primary care providers often lack the familiarity and expertise to educate guardians and monitor recovery, and prevention of neonatal brachial plexus palsy has not been possible by any individual physician or groups of physicians, as the injury occurs independent of physician experience [98, 27].

Operative

Indications: Surgical intervention for traumatic brachial plexus injuries is indicated only for patients without the likelihood of spontaneous or further recovery [89]. The major absolute contraindications to reconstruction are a patient’s unwillingness to undergo surgery or having unrealistic goals [89]. Relative contraindications include severe elbow or shoulder contracture, advanced age, medical comorbidities, and traumatic brain injury or cervical spinal cord injury [89]. Isolated C8-T1 injuries are a relative contraindication because more predictable results may be achieved with distal nerve and/or tendon transfers [89].

Surgical Approach / Technique: Current surgical treatment focuses on the restoration of motor function and protective sensation, though it does not address the severe neuropathic pain associated with avulsion injuries [89]. Nerve surgery is recommended within 6 months of injury; after 12 months, tendon transfers or free-functioning muscle transfers are considered [89]. Sharp, penetrating injuries should be explored and repaired acutely [89]. For blunt trauma, vascular injuries should be explored and repaired or reconstructed, while nerve roots should be tagged for future identification and reconstruction if applicable [89]. Gunshot wounds should be observed because they are typically neurapraxic in nature [89]. When nerve root avulsions (preganglionic injuries) are suspected, surgical intervention is typically recommended within 3 to 6 weeks after injury [89]. For suspected postganglionic injuries, a delay of 3-6 months may allow some recovery of injured nerves [89]. Nerve transfers or grafting yield worse outcomes in patients presenting between 6 and 12 months compared to early cases, and direct nerve transfer or grafting may not be advisable after 1 year due to motor end plate issues [89]. Alternative treatments such as free-functioning muscle transfers, tendon transfers about the shoulder, or shoulder arthrodesis should be considered after 1 year [89].

Treatment Priorities and Goals: 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 [89]. Modern patient-specific management can often permit consistent restoration of elbow flexion and shoulder stability with the potential of prehension of the hand [29]. In obstetrical brachial plexus palsy, different procedures are complementary and allow a good recovery of function of a nondominant limb in 75% of cases [7]. Because recovery from neurolysis or repair is always incomplete even in children, the constellation of sensory and motor deficits varies greatly from patient to patient [34]. In Narakas Group 2 brachial plexus birth palsy, more emphasis should be placed on shoulder internal rotation [56].

Surgical Techniques: Nerve Transfers and Grafting: 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 [36]. Indications have been extended from nerve root avulsion to post-ganglionic lesions due to excellent results of certain intraplexus nerve transfers [115]. Overall, nerve transfers have broadened reconstructive options and delivered more reliable results, with a particular improvement in outcome for reconstruction of the paralysed shoulder [55]. Nerve root avulsions cannot be repaired surgically because achieving functional continuity between the rootlets and the spinal cord is not currently possible; therefore, alternative methods of transferring functional motor nerves to affected terminal nerve branches distal to the injury are necessary [89]. 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 [89]. The development of microsurgical techniques and improved nerve grafting enables management of long nerve defects that could not be handled by neurorrhaphy [120]. Useful recovery was achieved in many patients by restoration of continuity by nerve grafts or neurolysis, and functional results were further improved by exploiting all available reconstructive techniques [120]. The authors recommend the use of intercostal nerves, rather than the phrenic nerve, for nerve transfer in brachial plexus injuries [112]. The technique of double neurotization from a single donor nerve provides favourable results in restoring shoulder abduction in avulsion brachial plexus injuries [100]. The seventh cervical nerve root transfer from the contralateral healthy side offers a new approach for the treatment of brachial plexus root avulsion [54]. This study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combined with patients' self-assessments [49]. Use of triceps motor branches of the radial nerve transfer to the axillary nerve should be considered in selected individuals with upper brachial plexus injuries [4]. The brachialis branch may be a successful donor for isolated and/or combined axillary nerve injuries, with good functional outcome and no residual deficit [13]. Many therapeutic options are available today for brachial plexus reconstruction, and no real consensus exists, but some tendencies and trends are apparent [15].

Surgical Techniques: Approaches and Adjuncts: The transclavicular approach expedites the approach to the brachial plexus with no complications to date [5]. Polyester tape scapulopexy outcomes 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]. Polyester tape scapulopexy was successful in patients with previous nerve transfers for shoulder motion restoration [38]. It is suggested that freeze-thawed skeletal muscle autografts may be applicable to repair of the human brachial plexus [25]. Mini-invasive robot-assisted surgery is possible for the brachial plexus [152].

Associated Injuries and Complications: An elbow joint with an incongruent ulnohumeral joint and limited passive motion will continue to have limited motion after reconstruction of the biceps [89]. It is important to anatomically reconstruct injured joints and long bones associated with brachial plexus injury [89]. Large soft-tissue defects and traumatic muscle loss may preclude reinnervation of the nerves to the affected muscles [89]. Loss of the biceps muscle will preclude reinnervation of the musculocutaneous nerve, and alternative treatments must be considered [89]. 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 [89]. Delayed fixation of clavicle fractures, especially between two and four weeks after injury, carries a small but significant risk of iatropathic brachial plexus injury [26]. Serious brachial plexus injury after median sternotomy is uncommon, with an incidence of 0.2% in the reported series [35].

Outcomes and Prognosis: 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 [9]. 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 [109].

Setting of Care: In the UK healthcare system, adopting a centralized approach for brachial plexus injuries ensures patients receive the highest quality of care [16]. Patients with brachial plexus injury following anterior shoulder dislocation should be immediately referred to a specialist brachial plexus service for assessment, physiotherapy, and the option of surgery if indicated [19]. Children with obstetric brachial plexus injury should be seen early by a hand surgeon dealing with brachial plexus injuries [21]. In a publicly funded healthcare system, only 45% of patients with obstetric brachial plexus injury were referred to multidisciplinary care [98]. A referral to a multidisciplinary center within one month is designated as "good" for obstetric brachial plexus injury [98].

Complications

Vascular Injuries: Combined subclavian artery and brachial plexus injury resulting from blunt trauma is a rare occurrence [22]. When this combined injury occurs, it results in devastating functional disability of the upper limb [22]. Axillary arterial entrapment can occur as a complication of proximal humeral fracture [23]. Additionally, false aneurysm can complicate a proximal humeral exostosis [39].

Nerve Palsy: Brachial plexus injury can occur as a complication of proximal humeral fracture [23]. Serious brachial plexus injury after median sternotomy is uncommon, with an incidence of 0.2% in the reported series [35]. Brachial plexus palsy can complicate a proximal humeral exostosis [39]. Radial nerve palsy can occur following procedures for proximal humeral exostosis [39]. Brachial plexus injury may be encountered even when a cesarean section is performed [116]. The risk of brachial plexus injury is increased for newborns with a birth weight over 4,500 g [116].

Mechanism-Specific Injury: The extrinsic system of the brachial plexus is susceptible to injury by acute stretching [33]. Acute stretching of the brachial plexus is a possible factor precipitating the onset of symptoms [33].

Parsonage-Turner Syndrome: Recurrence of Parsonage-Turner syndrome has been described at a rate of approximately 4% [110, 111]. Recovery from Parsonage-Turner syndrome is generally quicker when the proximal portion of the brachial plexus is involved [110, 111].

Recovery

Other Considerations: In patients undergoing assessment of median nerve motor recovery, 40% achieved function at the required follow-up interval of 2 years [122]. For patients with complete avulsion of the brachial plexus, double free-muscle transfer provided prehension despite poor sensory recovery [155]. Following a second procedure, radial nerve palsy recovered two months later, and one year later there was no clinical or radiological evidence of recurrence [39].

Key Evidence

• [L4] Injuries to the brachial plexus are far more common than is generally appreciated, but only a minority of patients are referred for specialist evaluation and treatment. [1] (10.1016/0266-7681(92)90018-w)
• [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. [2] (10.1111/sae.12003)
• [L4] In cases of complete brachial plexus lesions, it could also allow avoiding the morbidity of cervical exploration. [3] (10.1016/j.hansur.2019.10.125)
• [L4] Use of this technique should be considered in selected individuals with upper brachial plexus injuries. [4] (10.1007/s11552-012-9398-0)
• [L4] The authors found that the approach expedites the approach to the brachial plexus with no complications to date. [5] (10.1097/bth.0b013e3181644bdb)
• [L4] A better chance of recovery can also be expected for patients with closed injuries when brachial plexus explorations is done within 3 months of injury. [6] (10.1016/s0363-5023(09)91101-7)
• [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. [7] (10.1016/b978-0-444-52910-7.00014-3)
• [L4] Most cases of brachial plexus injury after shoulder dislocation have a good prognosis for recovery except for intrinsic muscles of the hand. [8] (10.1016/j.injury.2009.05.015)
• [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. [9] (10.1016/j.jhsa.2022.11.003)
• [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. [10] (10.3389/fneur.2023.1084223)
• [L4] The window of opportunity for successful primary neurosurgical treatment of infants with an upper brachial plexus birth injury extends past 3 to 8 months. [11] (10.1016/j.jhsb.2004.03.008)
• [L5] The author advocates for the use of the term 'birth brachial plexus injury' because the pathophysiology relates directly to the birthing process. [12] (10.1016/j.jhsa.2005.10.014)
• [L5] The brachialis branch may be a successful donor for isolated and/or combined axillary nerve injuries and the functional outcome is good with no residual deficit. [13] (10.1177/1753193412438499)
• [L4] The study performed a blind histopathological analysis compared to intraoperative nerve aspect in patients with brachial plexus birth injuries. [14] (10.1016/j.hansur.2021.03.003)
• [L5] Many therapeutic options are available today for brachial plexus reconstruction, and no real consensus exists, but some tendencies and trends are apparent. [15] (10.1016/j.main.2008.11.010)
• [L5] By adopting this approach, the UK healthcare system can ensure that patients with brachial plexus injuries receive the highest quality of care, paving the way for better health outcomes and innovations in surgical practice. [16] (10.1016/j.injury.2024.112002)
• [L3] Most obstetric brachial plexus injury patients with isolated absent or slowly recovering shoulder movements recover at least 90 degrees of abduction. [17] (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. [18] (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. [19] (10.1177/1753193421993088)
• [L4] In brachial plexus injury reconstruction, achieving a stable and dynamic shoulder girdle is a primary goal. [20] (10.1097/prs.0b013e3181881fc5)
• [L4] Children with OBPI should be seen early by a hand surgeon dealing with brachial plexus injuries. [21] (10.4103/0970-0358.90805)
• [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. [22] (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. [23] (10.1016/j.injury.2013.05.010)
• [L4] [24] (10.1016/0266-7681(94)90050-7)
• [Paper] It is suggested that the technique may be applicable to repair of the human brachial plexus. [25] (10.1016/s0266-7681(05)80237-2)
• [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. [26] (10.1302/0301-620x.95b1.29625)
• [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. [27] (10.1080/01443610802295880)
• [L4] [28] (10.1016/0266-7681(91)90100-3)
• [L5] Modern patient-specific management can often permit consistent restoration of elbow flexion and shoulder stability with the potential of prehension of the hand. [29] (10.5435/jaaos-d-18-00433)
• [Paper] These findings suggest that the extrinsic system of the brachial plexus is susceptible to injury by acute stretching, a possible factor precipitating the onset of symptoms. [33] (10.1016/s1058-2746(05)80065-5)
• [L5] Because recovery from brachial plexus neurolysis or repair always is incomplete even in children, the constellation of sensory and motor deficits varies greatly from patient to patient and resists an easy classification into patterns by nerve root level. [34] (10.1016/s0749-0712(21)00269-9)
• [L4] Serious brachial plexus injury after median sternotomy is uncommon, with an incidence of 0.2% in this series. [35] (10.1016/0363-5023(93)90362-7)
• [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. [36] (10.1016/j.injury.2020.04.015)
• [L4] Parents should not be discouraged from treatment of their child’s brachial plexus injury due to fear of surgical complications. [37] (10.1016/s0266-7681(02)00353-4)
• [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)
• [L5] Two months after the second procedure, the radial nerve palsy recovered, and one year later there was no clinical or radiological evidence of recurrence. [39] (10.1016/s0266-7681(97)80416-0)
• [L5] [42] (10.1097/01.bth.0000199972.16703.e1)
• [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. [43] (10.1177/17531934211045509)
• [L4] Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently. [45] (10.1016/j.jhsa.2021.09.009)
• [L5] The potential for delayed nerve injury following a fracture needs to be appreciated to prevent delays in diagnosis and treatment. [47] (10.1016/s0266-7681(05)80009-9)
• [L4] This study validated the effect of nerve transfers for global brachial plexus avulsions from objective MRC grading combining with patients' self-assessments. [49] (10.1016/j.injury.2012.02.006)
• [L4] The EFFUL classification system is an objective method of measuring residual function before and after treatment in patients with peripheral nerve injuries. [50] (10.1053/jhsu.2001.20159)
• [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. [51] (10.5435/jaaos-21-12-717)
• [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. [52] (10.1016/j.jse.2023.06.016)
• [L4] A new type of brachial plexus lesion, the intermediate palsy, has been defined to be added to the classical types, involving predominantly C7 with variable involvement of the upper or lower plexus. [53] (10.1016/0266-7681(91)90101-s)
• [L4] This operation offers a new approach for the treatment of brachial plexus root avulsion. [54] (10.1016/s0266-7681(05)80235-9)
• [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. [55] (10.1007/s12593-011-0031-1)
• [L3] The results suggest that more emphasis should be placed on shoulder internal rotation in treatment strategies. [56] (10.1177/1753193420964768)
• [L3] Distal nerve transfers are the preferred option for the reconstruction of elbow flexion in upper-type brachial plexus injuries, where possible. [57] (10.1142/s2424835520500332)
• [L4] [58] (10.1016/j.jhsg.2026.101112)
• [L4] This analysis of outcome provides evidence that in properly selected and evaluated children with pronation contractures of the forearm, secondary to obstetric brachial plexus injury, surgical reconstruction can improve both form and function in the limb. [59] (10.1016/s0266-7681(99)90023-2)
• [L5] However this, and all the other, classification systems cannot be used to evaluate the outcome of treatment, or to compare the pre- and postoperative status of the shoulder. [60] (10.1016/s0266-7681(02)00399-6)
• [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. [61] (10.1016/j.jse.2023.03.036)
• [L5] Pain in avulsion lesions of the brachial plexus represents the most significant impediment to rehabilitation. [96] (10.1016/s0894-1130(96)80039-1)
• [L4] [98] (10.3171/2015.6.peds14703)
• [L4] Targeted fascicular biopsy of the brachial plexus is an efficient diagnostic procedure and in highly selected cases can be offered as the initial procedure over distal cutaneous nerve biopsy. [99] (10.1016/j.hansur.2016.10.116)
• [L4] The technique of double neurotization from a single donor nerve provides favourable results in restoring shoulder abduction in avulsion brachial plexus injuries. [100] (10.1177/1753193416680725)
• [L5] Shoulder muscle imbalance alone causes neither subscapularis shortening nor internal rotation contracture. [101] (10.2106/jbjs.j.00943)
• [L4] [105] (10.1016/j.injury.2012.07.182)
• [Case_report] MRI should typically be performed before making a treatment decision to examine the brachial plexus for any discontinuity or kinking. [106] (10.1186/s12891-022-05601-5)
• [L4] The spatial orientation of the coracoid process differs significantly between affected and contralateral shoulders and is highly correlated with glenohumeral deformity. [107] (10.1186/1471-2474-11-237)
• [L4] Shoulder internal/external rotation in abduction and adduction is not interchangeable. [108] (10.1016/j.jhsa.2024.06.001)
• [L2] Since no successful treatment is available, restricted use of RT to the brachial plexus is warranted, especially when administered concomitantly with cytotoxic therapy. [109] (10.3109/02841869009096384)
• [L4] [110] (10.1016/s1058-2746(00)90037-5)
• [L4] [111] (10.1067/mse.2000.104091)
• [L2] The authors recommend the use of intercostal nerves, rather than the phrenic nerve, for nerve transfer in brachial plexus injuries. [112] (10.1016/s0266-7681(03)00210-9)
• [L5] The indications for nerve transfers have been extended from brachial plexus injuries with nerve root avulsion to post-ganglionic lesions due to the excellent results of certain intraplexus nerve transfers. [115] (10.1016/j.hansur.2016.11.007)
• [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. [116] (10.1159/000049410)
• [L4] [120] (10.1016/s0363-5023(77)80046-4)
• [L4] Tendon transfers reorient the arc of motion into more external rotation and abduction rather than increasing glenohumeral motion, highlighting the importance of scapulothoracic function for outcome determination. [121] (10.1016/j.jse.2024.06.027)
• [L4] Of the patients who had the required follow-up of 2 years to assess motor recovery of the median nerve, 40% achieved function - M3. [122] (10.1016/j.hansur.2016.05.006)
• [L4] Subscapularis muscle release performed before the 2nd year results in a balancing of the shoulder in over 50% of cases and prevents humeral head deformation. [123] (10.1016/s0363-5023(03)80310-6)
• [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. [125] (10.1055/s-0030-1253242)
• [L4] The study reports a significant long-term decrease in shoulder abduction despite maintenance of external rotation and improvement in elbow extension. [126] (10.1177/1753193409104552)
• [L4] [128] (10.1016/j.hansur.2015.09.001)
• [Paper] [129] (10.1002/jor.25173)
• [L4] [134] (10.1016/j.injury.2008.05.012)
• [L4] Subscapularis release is not always required to overcome internal rotation contracture, and secondary glenohumeral changes might be prevented with this approach. [135] (10.1016/j.jse.2011.01.004)
• [L5] Shoulder abduction >70°, combined external rotation >60° with extension >50°, and downward forces on the humeral shaft may risk causing brachial plexopathy. [136] (10.1016/j.jse.2017.11.030)
• [L3] [138] (10.1016/j.jhsb.2006.04.027)
• [L4] These results demonstrate that tendon transfers improve overall shoulder motion but do not reduce humeral head subluxation or enhance glenohumeral joint realignment. [142] (10.1016/j.jse.2005.11.004)
• [L4] Findings A3, D, and M indicated lesions in Zone I or II(+ I), so if all the roots are thus affected, exploration of the brachial plexus may not be necessary. [147] (10.1016/0266-7681(89)90017-x)
• [L4] Abduction is maintained over the long-term, but external rotation and internal rotation deteriorate, leading to functional impairment. [149] (10.1016/j.jses.2018.05.002)
• [L4] The medial rotation contracture of the shoulder in these children is a complex progressive deformity, which requires a selective and stepwise approach. [151] (10.1016/s0363-5023(03)80311-8)
• [L4] Ces cas cliniques illustrent la possibilité de réaliser des interventions mini-invasives du plexus brachial. [152] (10.1016/j.main.2012.10.087)
• [L5] Neonatal brachial plexus injuries result in structural changes in the affected bone, including reduced trabecular bone density and cartilage thinning. [153] (10.1016/j.injury.2020.02.118)
• [L4] The combination of all 3 modalities of investigation could predict the site of the lesion in 80% of patients in both intra- and extraforaminal injury and in 67% in those with a combination type of lesion. [154] (10.1016/j.jhsa.2003.08.004)
• [L4] Although sensory recovery in these patients was poor, double free-muscle transfer provided prehension for patients with complete avulsion of the brachial plexus. [155] (10.1016/s0363-5023(05)80097-8)

See Also

• Fractures
• Rotator Cuff

References

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