Can one-time excessive pressure from using crutches (crutch) cause a brachial plexus injury?

Brachial Plexus Injury from Crutch Pressure

Yes, a one-time incident with excessive pressure from crutches can cause brachial plexus injury, known as "crutch palsy." 1 This type of compressive neuropathy typically affects the posterior cord of the brachial plexus, which includes the radial nerve, though the ulnar and median nerves can also be involved.

Mechanism of Injury

• Improper crutch use with excessive pressure in the axilla can compress the brachial plexus against the first rib or clavicle
• The posterior cord (predominantly affecting radial nerve function) is most commonly affected 1
• The compression can cause a range of nerve injuries from mild neuropraxia to severe axonotmesis

Clinical Presentation

Patients with crutch-induced brachial plexus injury may present with:

• Weakness or paralysis in the affected limb, particularly wrist and finger extension (radial nerve)
• Sensory loss in nerve distribution patterns
• Neuropathic pain, dysesthesia, or burning/electric sensations
• Flaccid loss of tendon reflexes 2

Diagnosis

• MRI of the brachial plexus is the gold standard imaging modality (sensitivity 84%, specificity 91%) 2
• Imaging should be delayed until approximately one month after trauma to allow resolution of hemorrhage and edema 3
• Electromyography (EMG) can confirm the presence and severity of nerve injury, distinguishing between neuropraxia and axonotmesis 1

Treatment Approach

1. Immediate Management:

   • Discontinue use of axillary crutches
   • Switch to alternative mobility aids (forearm crutches, walker, or wheelchair)
   • Provide appropriate splinting (e.g., cock-up wrist splint for radial nerve palsy) 1

2. Conservative Management:

   • Most cases resolve spontaneously within 8-12 weeks
   • However, severe cases with axonotmesis may take up to 9 months for recovery 1
   • Physical therapy including:
     • Passive range of motion exercises
     • Muscle stretching and strengthening
     • Sensory re-education strategies 4

3. Surgical Intervention:

   • Rarely needed for crutch palsy
   • Consider if no signs of recovery within 3-6 months 2
   • Surgical options include nerve repair, grafting, or transfers depending on injury severity

Prognosis

• Mild cases (neuropraxia) typically recover completely within 2-3 months
• Severe cases (axonotmesis) may take 6-9 months for recovery 1
• Complete recovery is possible but depends on the severity of the initial nerve injury

Prevention

• Proper crutch fitting and education on correct use
• Weight should be borne through the hands, not the axilla
• Crutch top should be 2-3 finger widths below the axilla
• Regular breaks from crutch use when possible
• Consider alternative mobility aids if prolonged use is necessary

Important Caveats

• Bilateral involvement is possible, as documented in case reports 1
• Delayed diagnosis is common as symptoms may develop gradually after initial crutch use
• Patients with pre-existing neuropathies or diabetes may be at higher risk for compression injuries
• Continued compression can worsen the injury and prolong recovery time