Brachial Plexus Injury

Background

Peripheral nerve injuries are not common in noncontact sports. However, in contact and collision sports like football and rugby, brachial plexus injuries occur often. The greater incidence of brachial plexus injuries has been suggested to be the result of direct trauma from participation in contact sports.

The result of trauma to the brachial plexus can lead to the cervical "stinger" or "burner" syndrome, which is classically characterized by unilateral weakness and a burning sensation that radiates down an upper extremity. The condition may last less than a minute or as long as 2 weeks, with the latter duration described as a chronic burner syndrome.

Frequency

United States

Brachial plexus injuries are the most common peripheral nerve injuries seen in athletes. True rate of brachial plexus injuries is difficult to determine due to significant underreporting. Many stingers last briefly and players do not seek medical attention. Clancy et al reported that 33 of 67 college football players (49%) sustained at least 1 burner during collegiate play. Sallis et al surveyed Division III college football players and reported that 65% experienced brachial plexus injuries. In addition, Sallis reported an 87% recurrence rate in these individuals. Meeuwisse reported that 7.2% of all football injuries were brachial plexus injuries.

International

True measure of international occurrence of brachial plexus injuries is undetermined due to significant underreporting in athletes and lack of studies in rugby and hockey involving brachial plexus injuries.

Functional Anatomy

Injuries to the cervical spine are common. The common level of injury is at C5-C6. Damage to other areas of the spinal area can lead to an array of motor and sensory deficits. The following is a list of cervical nerve roots with the associated area of potential motor and sensory deficits:

• C4 - Trapezius; shoulder; top of shoulders
  

• C5 - Deltoid, rotator cuff; shoulder abduction; lateral upper arm or distal radius
  

• C6 - Biceps, rotator cuff; elbow flexion; lateral forearm and thumb
  

• C7 - Triceps; elbow extension; index and middle finger tips
  

• C8 - Extension of fingers; distal thumb; fourth and fifth fingers

Sport Specific Biomechanics

The following 3 mechanisms are common to brachial plexus injury:

1. Traction caused by lateral flexion of the neck away from the involved side (similar to the mechanism in birth trauma)
   

1. Direct impact to the Erb point causing compression to the brachial plexus (often associated with poor-fitting shoulder pads)
   

1. Nerve compression caused by neck hyperextension and ipsilateral rotation (The neural foramen narrows in this mechanism.)

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

At onset of injury, nonsteroidal anti-inflammatory drugs (NSAIDs), early mobilization, and moist heat packs are the favorable methods of treatment for acute injuries. In the subacute phase, a gradual progression from ROM activity to cervical and shoulder muscle strengthening is recommended.

Medical Issues/Complications

If symptoms persist (eg, persistent weakness, chronic neurapraxia) regardless of therapy, further consideration for additional imaging and referral should be undertaken.

Surgical Intervention

Surgical intervention is rarely needed, is injury-specific, and should be directed by a neurosurgical or orthopedic spine surgeon.

Consultations

Neurosurgery spine/orthopedic spine

Other Treatment

Manipulation is not recommended as a first line intervention, but it may be a helpful adjunct after full medical assessment has been completed.

Recovery Phase

Rehabilitation Program

Physical Therapy

In the recovery phase, cervical muscle strengthening and conditioning should be continued. Strength training programs are used to fully recover the strength that the athlete had prior to the injury. Training should be focused on muscles supporting the injured brachial plexus nerve, such as the shoulders and the surrounding cervical spine region. The neck also should be protected (eg, use of cervical neck rolls, cervical pillows) until strength is regained.

Consultations

If needed, continue follow-up care with a neurologist, and/or spine specialist.

Maintenance Phase

Rehabilitation Program

Physical Therapy

Continued maintenance of cervical muscle strength, conditioning, and protection is recommended.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Opiate-Narcotics

Analgesia is important to obtain in the setting of brachial plexus nerve injuries. This can be accomplished by use of anti-inflammatory and/or opiate-narcotic medications. Analgesia may facilitate further assessment of the athlete, as well as their willingness to participate in therapy sessions.

Drug Name	Hydrocodone and acetaminophen (Lortab, Norcet, Vicodin)
Description	Drug combination indicated for moderate to severe pain.
Adult Dose	1-2 tab PO q4-6h prn
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Interactions	Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Pregnancy	D - Unsafe in pregnancy
Precautions	Tablets contain metabisulfite which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction; may cause drowsiness (Do not drive heavy machinery while taking medication)

Drug Name	Hydrocodone and ibuprofen (Vicoprofen)
Description	Drug combination indicated for short-term (less than 10 d) relief of moderate to severe acute pain
Adult Dose	1-2 tab PO q4-6h prn pain; not to exceed 5 tab/d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; 3rd trimester of pregnancy
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in impaired renal function, peptic ulcer disease, impaired thyroid function, asthma, hypertension, edema, heart failure, increased intracranial pressure, and erosive gastritis; duration of action may increase in elderly patients

Drug Name	Oxycodone and acetaminophen (Percocet, Roxicet, Roxilox, Tylox)
Description	Drug combination indicated for the relief of moderate to severe pain.
Adult Dose	1-2 tab or cap PO q4-6h prn pain
Pediatric Dose	0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn
Contraindications	Documented hypersensitivity
Interactions	Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/d of acetaminophen; higher doses may cause liver toxicity

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Have analgesic and antiinflammatory activities. Their mechanism of action is not known, but may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Drug Name	Ibuprofen (Motrin, Ibuprin)
Description	DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose	600-800 mg PO tid prn
Pediatric Dose	10 mg/kg/dose PO q6h
Contraindications	Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Name	Ketoprofen (Oruvail, Orudis, Actron)
Description	For relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Name	Naproxen (Naprosyn, Naprelan, Anaprox)
Description	For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.
Adult Dose	500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose	<2 years: Not established >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug