Managing Brachial Plexus Injuries for Adult & Pediatric Patients

Injuries to the brachial plexus are devastating, and their presentation and treatment vary depending on the location within the brachial plexus, the timing of the injury and the mechanism of the injury.
Some brachial plexus injuries can be managed with physical therapy, pain medication and clinical surveillance, while others require surgery, for which there is no one-size-fits-all option.

“The type of surgery performed for a brachial plexus injury depends on the mechanism and timing of the injury, the clinical presentation, and the results of a patient’s work-up,” says Dr. Dane Daley, an orthopaedic hand surgeon at MUSC Health. “After the patient is evaluated clinically and a thorough work-up is completed, then I can determine what type of intervention will provide the patient with the most optimal outcome.”

The brachial plexus is a network of five nerves that transmits signals from the brain to control the function of the upper extremity. Minor injuries, such as stingers, can occur in contact sports. Severe injuries can result from trauma, such as car accidents, knife or gunshot wounds. Brachial plexus injuries can also be caused by tumors, radiation, or during childbirth. Injuries can range from avulsion injuries in which the nerves rupture from the spinal cord, stretch injuries, which can be transient, or a transection of the nerve after exiting the spinal cord.

Injuries to the brachial plexus cause a myriad of symptoms, including pain, numbness, weakness or paralysis in the shoulder, arm, or hand. These injuries are life-changing and require a multi-disciplinary approach to treating the whole patient. This often includes an occupational therapist, psychologist/psychiatrist and pain management physician, Dr. Daley says.

Surgical options differ, based on the timing of the injury, and include brachial plexus reconstruction with nerve grafts, nerve transfers or tendon transfers, among others. Surgical management is tailored to the patient’s specific injury.

Dr. Daley is one of a few surgeons in South Carolina who is trained to perform these complex operations, as well as other reconstructive procedures, on pediatric and adult patients.

Brachial plexus reconstruction involves replacing injured nerves of the brachial plexus with a nerve graft that is harvested from a nerve elsewhere in the body (autograft) or from a cadaveric nerve (allograft).

Nerve transfers are performed when reconstruction is not feasible and/or in conjunction with a reconstruction to provide the patient with the best possible outcome. They are also performed pending the timing and level of injury, for instance in the setting of a nerve root avulsion. In this procedure, Dr. Daley transfers a nearby functioning nerve and connects it to a nerve that no longer works, with the goal of restoring innervation through the nerve transfer to the muscle.

Tendon transfer surgery involves utilizing a nearby functioning muscle and repurposing it by moving its associated tendon to restore a function that the patient no longer has as a result of their injury. “Essentially, we’re playing a trick on the mind by utilizing a muscle that was designed for one function and moving it to create a different function that is missing or critical to upper extremity function,” he says.

His patients, most of whom are young- to middle-age males, come from across the Southeast for evaluations and surgery. These complex surgeries can range from two to eight hours, depending on the number of injured nerves, the complexity of the surgery, as well as the mechanism and timing of the injury.

“Sharply transected and/or most open brachial plexus injuries do well with urgent exploration and direct repair or reconstruction, whereas other mechanisms of injury and their subsequent surgery depend largely on the clinical exam, history of the injury, and the results of sequential nerve studies,” he says. “I determine what nerves are injured and what nerves are functioning; then I have to determine if the injury is amenable to a reconstruction or nerve transfers. There’s not a set surgery for every brachial plexus patient.”

Timing is critical in nerve and brachial plexus surgery and is the single biggest factor affecting outcome. “If too much time has elapsed, nerve transfer surgery or brachial plexus reconstruction options aren’t possible. That’s because when a nerve is cut, the muscle no longer receives the signal to function, and there is a progressive decline of muscle viability and thus its ability to be reinnervated,” Dr. Daley says.

“Nerve regeneration and thus clinical improvement, can take six months or longer, depending on the level of the injury,” he says.

“Oftentimes I prescribe preoperatively physical therapy for my patients to keep their shoulder, wrist, elbow, and/or finger joints flexible,” he says. “This therapy continues post-operatively while we wait for the nerves to recover and heal.”

If a patient sustains a brachial plexus injury, then Dr. Daley would clinically evaluate the patient and discuss options for managing the injury.

Although different approaches to managing brachial plexus injuries are available at MUSC Health, one aspect of treatment and care is constant: “We have everything at MUSC. Our supportive staff, neurologists, physiatrists, mental health professionals, and occupational and physical therapists are dedicated to working with patients to restore as much function as possible physically and mentally.”

Dr. Daley specializes in orthopedics and hand surgery. His clinical interests include but are not limited to brachial plexus injuries, peripheral nerve injuries, targeted muscle reinnervation, tendon transfer surgery, carpal tunnel syndrome, Dupuytrens disease, trauma, osteoarthritis and rheumatoid arthritis. To make an appointment or a referral, call 843-876-0111.