Management of brachial plexus injuries

  • G. Blaauw
  • R. S. Muhlig
  • J. W. Vredeveld
Part of the Advances and Technical Standards in Neurosurgery book series (NEUROSURGERY, volume 33)


Most brachial plexus lesions are traction injuries sustained during birth, but in adolescents and older people they are usually caused by traffic accidents or following a fall in the home. A minority are the result of penetrating injury after civilian assault or trauma encountered during wartime.

Birth palsy cases (obstetric brachial plexus palsy) and the remaining cases (traumatic brachial plexus palsy) are viewed differently with regard to treatment and outcome and so these two groups are usually discussed in separate chapters. In this paper we treat both groups in parallel because as far as primary (= nerve) surgery is concerned, many treatment problems and solutions are present in both groups and are therefore comparable.


Brachial plexus injuries birth palsy obstetric brachial plexus palsy traumatic brachial plexus palsy management of brachial plexus injuries 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Al-Qattan MM, Clarke HM, Curtis CG (1995) Klumpke’s birth palsy: does it really exist? J Hand Surg (Br) 20: 19–23CrossRefGoogle Scholar
  2. 2.
    Alnot J-Y (1988) Traumatic brachial plexus palsy in adults. In: Raoul Tubiana (ed) The hand, vol. III. WB Saunders, Philadelphia, pp 607–644Google Scholar
  3. 3.
    Bae DS, Waters PM, Zurakowski D (2003) Reliability of three classification systems measuring active motion in brachial plexus birth palsy. J Bone Joint Surg 85: 1733–1738PubMedGoogle Scholar
  4. 4.
    Bager B (1997) Perinatally acquired brachial plexus palsy — a persisting challenge. Acta Paediatr 86: 1214–1219PubMedCrossRefGoogle Scholar
  5. 5.
    Berman JS, Birch R, Anand P (1998) Pain following human brachial plexus injury with spinal cord avulsion and the effect of surgery. Pain 75: 199–207PubMedCrossRefGoogle Scholar
  6. 6.
    Berthold CH, Carlstedt T, Corneliuson O (1993) Anatomy of the mature transitional zone. In: Dyck PJ, Thomas PK, Griffin JW, Low PA, Poduslo JF (eds) Peripheral neuropathy, 3rd edn. WB Saunders, Philadelphia, pp 75–80Google Scholar
  7. 7.
    Birch R (1996) Brachial plexus injuries. J Bone Joint Surg 78-B: 986–992CrossRefGoogle Scholar
  8. 8.
    Birch R, Bonney G, Wynn Parry CB (1998) Surgical disorders of the peripheral nerves. Churchill Livingstone, Edinburgh, pp 398–404Google Scholar
  9. 9.
    Birch R, Ahad N, Kono H, Smith (2005) Repair of obstetric brachial plexus palsy. Results in 100 children. J Bone Joint Surg (Br) 87-B: 1089–1095CrossRefGoogle Scholar
  10. 10.
    Bisinella GL, Birch R, Smith SJM (2003) Neurophysiological prediction of outcome in obstetric lesions of the brachial plexus. J Hand Surg 28B: 148–152Google Scholar
  11. 11.
    Blaauw G, Pons C (1999) Letsels van de plexus brachialis. Elsevier/Bunge, Maarssen, pp 36–38Google Scholar
  12. 12.
    Blaauw G, Slooff ACJ (2003) Transfer of pectoral nerves to the musculocutaneous nerve in obstetric upper brachial plexus palsy. Neurosurgery 53: 338–341PubMedCrossRefGoogle Scholar
  13. 13.
    Blaauw G, Muhlig RS, Kortleve JW, Tonino AJ (2004) Obstetric brachial plexus injuries following breech delivery: an adverse experience in The Netherlands. Semin Plast Surg 18: 301–307CrossRefGoogle Scholar
  14. 14.
    Blaauw G, Sauter Y, Lacroix CLE, Slooff ACJ (2006) Hypoglossal nerve transfer in obstetric brachial plexus palsy. J Plast Reconstr Aesthetic Surg 59: 474–478CrossRefGoogle Scholar
  15. 15.
    Bonnard C, Allieu Y, Alnot J-Y, Brunelli G, Merle M, Santos-Palazzi A, Sedel L, Raimondi PL, Narakas A (1996) Complete palsies and supraclavicular lesions. In: Alnot J-Y, Narakas A (eds) Traumatic brachial plexus injuries, Monographie de la Societé Française de Chirurgie de la Main (GAM). Expansion Scientifique Française, Paris, pp 126–155Google Scholar
  16. 16.
    Bonney G, Gilliatt RW (1958) Sensory nerve conduction after traction lesion of the brachial plexus. Proc R Soc Med 51: 365–367PubMedGoogle Scholar
  17. 17.
    Carlstedt T, Anand P, Hallin R, Misra PV, Norén G, Seferlis T (2000) Spinal nerve root repair and reimplantation of avulsed ventral roots into the spinal cord after brachial plexus injury. J Neurosurg Spine 93: 237–247Google Scholar
  18. 18.
    Clarke HM, Curtis CG (1995) An approach to obstetrical brachial plexus injuries. Hand Clin 11: 563–581PubMedGoogle Scholar
  19. 19.
    Colon AJ, Vredeveld JW, Blaauw G, Zandvoort JA (2003) Spontaneous muscle fiber activity appears early in cases of obstetric brachial plexopathy. Muscle Nerve 28: 515–516PubMedCrossRefGoogle Scholar
  20. 20.
    Colon AJA, Vredeveld JW, Blaauw G, Slooff ACJ, Richards R (2003) Extensive somatosensory innervation in infants with obstetric brachial palsy. Clin Anat 16: 25–29PubMedCrossRefGoogle Scholar
  21. 21.
    Curtis C, Stephens D, Clarke HM, Andrews D (2002) The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy. J Hand Surg 27A: 470–478Google Scholar
  22. 22.
    Doi K (2001) Palliative surgery: free muscle transfers. In: Gilbert A (ed) Brachial plexus injuries. Martin Dunitz, London, pp 137–147Google Scholar
  23. 23.
    Doi K, Otsuka K, Okamoto Y, Fujii H, Hattori Y, Baliarsing AS (2002) Cervical nerve root avulsion in brachial plexus injuries: magnetic resonance imaging classification and comparison with myelography and computerized tomography myelography. J Neurosurg 96Suppl 3: 277–284PubMedGoogle Scholar
  24. 24.
    Evans-Jones G, Kay SPJ, Weindling AM, Cranny G, Ward A, Bradshaw A, Hernon C (2003) Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and republic of Ireland. Arch Dis Child Fetal Neonatal Ed 88: F185–F189PubMedCrossRefGoogle Scholar
  25. 25.
    Fairbank HAT (1913) Birth palsy: subluxation of the shoulder-joint in infants and young children. Lancet 1: 1217–1223Google Scholar
  26. 26.
    Frazier CH, Skillern PF (1911) Supraclavicular subcutaneous lesions of the brachial plexus not asociated with skeletal injuries. J Am Med Ass 57: 1957–1963Google Scholar
  27. 27.
    Gilbert A, Tassin JL (1984) Réparation chirurgicale du plexus brachial dans la paralysie obstétricale. Chirurgie 110: 70–75PubMedGoogle Scholar
  28. 28.
    Gilbert A (1995) Long-term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin 11: 583–594PubMedGoogle Scholar
  29. 29.
    Gilbert A (2001) Results of repair to the brachial plexus. In: Gilbert A (ed) Brachial plexus injuries. Martin Dunitz, London, pp 211–215Google Scholar
  30. 30.
    Gilbert A, Pivato G, Kheiralla T (2006) Long-termresults of primary repair of brachial plexus lesions in children. Microsurgery 26: 334–342PubMedCrossRefGoogle Scholar
  31. 31.
    Gordon M, Rich H, Deutschberger JD, Green M (1973) The immediate and long-term outcome of obstetric birth trauma. Am J Obstet Gynecol 117: 51–56PubMedGoogle Scholar
  32. 32.
    Gramsbergen A, IJkema-Paassen J, Nikkels PGJ, Hadders-Algra M (1997) Regression of polyneural innervation in the human psoas muscle. Early Hum Dev 49: 49–61PubMedCrossRefGoogle Scholar
  33. 33.
    Greenwald AG, Schute PC, Shively JL (1984) Brachial plexus birth palsy: a 10-year report on the incidence and prognosis. J Pediatr Orthop 4: 689–692PubMedGoogle Scholar
  34. 34.
    Haerle M, Gilbert A (2004) Management of complete obstetric brachial plexus lesions. J Pediatr Orthop 24: 194–200PubMedGoogle Scholar
  35. 35.
    Hoffer MM, Phipps GJ (1998) Closed reduction and tendon transfer for treatment of dislocation of the glenohumeral joint secondary to brachial plexus birth palsy. J Bone Joint Surg 80A: 997–1001Google Scholar
  36. 36.
    Kline DG, Hudson AR (1995) Nerve injuries. Operative results for major nerve injuries, entrapments, and tumors. W.B. Saunders, Philadelpphia, pp 345–471Google Scholar
  37. 37.
    Kline DG, Hudson AR, Kim DH (2001) Atlas of peripheral nerve surgery. W.B. Saunders, Philadelphia, pp 1–75Google Scholar
  38. 38.
    La Scala GC, Rice SB, Clarke HM (2003) Complications of microsurgical reconstruction of obstetrical brachial plexus palsy. Plast Reconstruct Surg 111: 1383–1390CrossRefGoogle Scholar
  39. 39.
    L’Episcopo JB (1934) Tendon transplantation in obstetrical paralysis. Am J Surg 25: 122CrossRefGoogle Scholar
  40. 40.
    Mallet J (1972) Paralysie obstetricale du plexus brachial: traitement des sequelles. Primauté du traitement de l’épaule — Méthode d’expression des résultats. Rev Chir Orthop Reparatrice Appar Mot 58Suppl 1: 166–168PubMedGoogle Scholar
  41. 41.
    Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF (1994) The natural history of obstetrical brachial plexus palsy. Plast Reconstruct Surg 93: 675–681Google Scholar
  42. 42.
    Millesi H (1992) Chirurgie der peripheren Nerven. Urban & Schwarzenberg, München, pp 79–120Google Scholar
  43. 43.
    Mollberg M, Hagberg H, Bager B, Lilja H, Ladfors L (2005) Risk factors for obstetric brachial plexus palsy among neonates delivered by vacuum extraction. Obstetric Gynecol 106: 913–918Google Scholar
  44. 44.
    Muhlig RS, Blaauw G, Slooff ACJ, Kortleve JW, Tonino AJ (2001) Conservative treatment of obstetrical brachial plexus palsy (obpp) and rehabilitation. In: Gilbert A (ed) Brachial plexus injuries. Martin Dunitz, London, pp 173–187Google Scholar
  45. 45.
    Murphey F, Hartung W, Kirklin JW (1947) Myelographic demonstration of avulsing injury of the brachial plexus. Am J Roentgenol 58: 102–105Google Scholar
  46. 46.
    Narakas AO (1986) Injuries to the brachial plexus. In: Bore FW (ed) The pediatric upper extremity. Diagnosis and management. W. B. Saunders Company, Philadelphia, pp 247–258Google Scholar
  47. 47.
    Narakas AO (1987) Obstetrical brachial plexus injuries. In: Lamb DW (ed) The paralysed hand. (The hand and upper limb, vol. 2). Churchill Livingstone, Edinburgh, pp 116–135Google Scholar
  48. 48.
    Narakas AO (1991) Neurotization in the treatment of brachial plexus injuries. In: Gelberman RH (ed) Operative nerve repair and reconstruction. JB Lippincott Company, Philadelphia, pp 1329–1358Google Scholar
  49. 49.
    Nashold BS Jr, Ostdahl RH (1979) Dosal root entry zone lesions for pain relief. J Neurosurg 51: 59–69PubMedGoogle Scholar
  50. 50.
    Ostdahl RH (1996) DREZ surgery for brachial plexus avulsion pain. In: Nashold BS, Pearlstein RD (eds) The DREZ operation. The American Association for Neurological Surgeons, Illinois, pp 105–124Google Scholar
  51. 51.
    Pitt M, Vredeveld JW (2005) The role of electromyography in the management of the brachial plexus palsy of the newborn. Clin Neurophysiol 116: 1756–1761PubMedCrossRefGoogle Scholar
  52. 52.
    Pondaag W, Malessy MJA, Van Dijk JG, Thomeer RTWM (2004) Natural history of obstetric brachial plexus palsy: a systematic review. Dev Med Child Neurol 46: 138–144PubMedCrossRefGoogle Scholar
  53. 53.
    Rankine JJ (2004) Adult traumatic brachial plexus injury. Clin Radiol 59: 767–774PubMedCrossRefGoogle Scholar
  54. 54.
    Rexed D (1952) The cytoarchitectonic organization of the spinal cord in the cat. J Comp Neurol 96: 414–495PubMedCrossRefGoogle Scholar
  55. 55.
    Schenker M, Birch R (2001) Diagnosis of the level of intradural rupture of the rootlets in traction lesions of the brachial plexus. J Bone Joint Surg 83-B: 916–920CrossRefGoogle Scholar
  56. 56.
    Seddon H (1972) Surgical disorders of the peripheral nerves. Churchill Livingstone, Edinburgh London, pp 32–36, 174–198Google Scholar
  57. 57.
    Sever JW (1918) The results of a new operation for obstetrical paralysis. Am J Orthop Surg 16: 248–257Google Scholar
  58. 58.
    Sindou MP, Fischer G, Goutelle A, Mansuy L (1974) La radicellotomie posterieure selective. Premiers resultats dans la chirurgie de la douleur. Neurochirurgie 20: 391–408PubMedGoogle Scholar
  59. 59.
    Sindou MP, Blondet E, Emery E, Mertens P (2005) Microsurgical lesioning in the dorsal root entry zone for pain due to brachial plexus avulsion: a prospective series of 55 patients. J Neurosurg 102: 1018–1028PubMedGoogle Scholar
  60. 60.
    Smith SJM (1996) The role of neurophysiological investigation in traumatic brachial plexus lesions in adults and children. J Hand Surg 21: 145–148Google Scholar
  61. 61.
    Smith SJM (1998) Electrodiagnosis. In: Birch R, Bonney G, Wynn Parry CB (eds) Surgical disorders of the peripheral nerves. Churchill Livingstone, Edinburgh, pp 482–487Google Scholar
  62. 62.
    Specht EE (1975) Brachial plexus palsy in the newborn. Incidence and prognosis. Clin Orthop 110: 32–34PubMedCrossRefGoogle Scholar
  63. 63.
    Steindler A (1918) A muscle plasty for the relief of flail elbow in infantile paralysis. Inter Med J 35: 235–241Google Scholar
  64. 64.
    Sunderland S (1968) Nerves and nerve injuries. Churchill Livingstone, Edinburgh London, 633 ppGoogle Scholar
  65. 65.
    Tan KL (1973) Brachial palsy. J Obstet Gynaecol Br Commonw 80: 60–62PubMedGoogle Scholar
  66. 66.
    Thomas DGT, Kitchen ND (1994) Long term follow up of dorsal root entry zone lesions in brachial plexus avulsion. J Neurol Neurosurg Psychiatr 57: 737–738PubMedCrossRefGoogle Scholar
  67. 67.
    Torode I, Donnan L (1998) Posterior dislocation of the humeral head in association with obstetrical paralysis. J Pediatr Orthop 18: 611–615PubMedCrossRefGoogle Scholar
  68. 68.
    Troum S, Floyd WED, Waters PM (1993) Posterior dislocation of the humeral head in infancy associated with obstetrical paralysis. A case report. J Bone Joint Surg 75-A: 1370–1375Google Scholar
  69. 69.
    Ubachs JHM, Slooff ACJ, Peeters LLM (1995) Obstetric antecedents of surgical treated obstetric brachial plexus injuries. Br J Obstet Gynaecol 102: 813–817PubMedGoogle Scholar
  70. 70.
    Van Dijk JG, Pondaag W, Malessy MJ (2001) Obstetric lesions of the brachial plexus. Muscle Nerve 24: 1451–1461PubMedCrossRefGoogle Scholar
  71. 71.
    Van Egmond C, Tonino A, Kortleve JW (2001) Steindler flexorplasty of the elbow in obstetric brachial plexus injuries. J Pediatr Orthop 21: 169–173PubMedCrossRefGoogle Scholar
  72. 72.
    Vredeveld JW, Blaauw G, Slooff ACJ, Richards R (1997) “Luxury innervation”: does it exist and play a role at the time of birth? Electroencephalogr Clin Neurophysiol 107: 1Google Scholar
  73. 73.
    Vredeveld JW, Blaauw G, Slooff ACJ, Richards R, Rozeman CAM (2000) The findings in paediatric obstetric brachial palsy differ from those in older patients: a suggested axplanation. Dev Med Child Neurol 42: 158–161PubMedCrossRefGoogle Scholar
  74. 74.
    Vredeveld JW, Slooff BCJ, Blaauw G, Richards R (2001) Validation of an electromyography and nerve conduction study protocol for the analysis of brachial plexus lesions in 184 consecutive patients with traumatic lesions. J Clin Neuromusc Dis 2: 123–128CrossRefGoogle Scholar
  75. 75.
    Wickstrom J, Haslam ET, Hutchinson RH (1955) The surgical management of residual deformities of the shoulder following birth injuries of the brachial plexus. J Bone Joint Surg 27A: 27–36Google Scholar
  76. 76.
    Wynn Parry CB (1984) Pain in avulsion of the brachial plexus. Neurosurgery 15: 960–965CrossRefGoogle Scholar

Copyright information

© Springer-Verlag/Wien 2008

Authors and Affiliations

  • G. Blaauw
    • 1
  • R. S. Muhlig
    • 2
  • J. W. Vredeveld
    • 3
  1. 1.Department of NeurosurgeryUniversity HospitalMaastrichtThe Netherlands
  2. 2.Rehabilitation Out-Patient ClinicS.G.L.HeerlenThe Netherlands
  3. 3.Department of NeurophysiologyAtrium Medical CentreHeerlenThe Netherlands

Personalised recommendations