Treatment of Brachial Plexus Injuries
The treatment of brachial plexus injuries requires an integrated approach combining early surgical intervention for complete ruptures and penetrating injuries, with delayed surgical decision-making for blunt injuries after approximately 1 month of observation, followed by comprehensive rehabilitation regardless of surgical status. 1, 2
Initial Management Algorithm
Timing of Intervention Based on Injury Type
Penetrating and open injuries require early surgical exploration to assess nerve integrity and perform immediate repair when indicated 1, 2. These injuries typically involve complete nerve disruption requiring direct surgical management.
Blunt and closed injuries should be observed for approximately 1 month before definitive surgical planning to allow hemorrhage and edema resolution, which enables accurate assessment of nerve integrity on MRI and clinical examination 1, 2, 3. During this observation period, initiate rehabilitation interventions immediately (see below).
Surgical Decision-Making
Complete nerve ruptures require early operative management as they have poor prognosis without intervention and will not recover spontaneously 1, 2. Surgical options include:
- Nerve exploration and neurolysis for nerves in continuity with conduction block 4
- Nerve grafting for segmental nerve defects 4
- Nerve transfer procedures for proximal injuries or when donor nerves are unavailable 4
- Primary reconstruction should occur within 6 months of injury for optimal outcomes, particularly for shoulder and elbow function restoration 4
Preganglionic injuries (root avulsions) versus postganglionic injuries require different reconstruction approaches, making this distinction critical during surgical planning 2. MRI can identify pseudomeningoceles as surrogate markers for root avulsion 3.
Rehabilitation Protocol
Immediate Phase (All Patients, Regardless of Surgical Status)
Begin rehabilitation interventions immediately upon diagnosis, not after waiting for spontaneous recovery or surgical intervention 5. Rehabilitation is beneficial during all recovery stages including spontaneous recovery, postoperative period, and sequelae period 5.
Core rehabilitation modalities include:
- Kinesiotherapy with range of motion exercises, muscle stretching, and strengthening to prevent contractures and maintain joint mobility 6
- Sensory re-education strategies to optimize functional recovery 6
- Manual therapy techniques 6
- Neuroelectromagnetic stimulation 5
Postoperative Rehabilitation
Following surgical reconstruction, continue intensive rehabilitation focusing on:
- Exercise therapy tailored to the specific nerve repairs or transfers performed 5
- Management of postoperative edema and pain, which are often neglected but significantly impact outcomes 5
- Electrothermal and phototherapy modalities as adjuncts 6
Secondary Reconstruction (Late Presentation or Failed Primary Reconstruction)
For patients presenting more than 12 months after injury or when primary reconstruction fails, secondary procedures focus on restoring elbow flexion and shoulder stability 7.
Free-functioning muscle transfer is the primary technique for elbow flexion restoration in delayed settings, with double free-functioning muscle transfers potentially providing rudimentary prehension 4, 7. This represents a powerful tool for both primary and delayed reconstruction 4.
Tendon transfers and arthrodesis procedures provide additional options for improving upper extremity function when nerve reconstruction is not feasible 4, 7.
Shoulder reconstruction focuses on glenohumeral joint stability and abduction restoration through various surgical techniques 7.
Critical Treatment Principles
Nerve repair alone is insufficient—only the combination of nerve repair with muscle and tendon transfer procedures can restore functional arm use 8. This integrated concept is essential for optimal outcomes.
A multidisciplinary team approach is mandatory, led by a peripheral nerve surgeon and including hand therapists, electrodiagnosticians, mental health experts, and pain management specialists 4. The mental health implications and economic impacts are substantial and require dedicated attention 4.
Common Pitfalls to Avoid
Do not delay imaging beyond 1 month for blunt injuries, as this represents the optimal window for surgical planning when hemorrhage has resolved but before irreversible muscle atrophy occurs 1, 2, 3.
Do not rely on standard rehabilitation protocols—treatment must be tailored to the specific injury pattern, surgical procedures performed, and recovery stage 5. However, the low level of evidence and unclear treatment parameters in the literature make protocol reproducibility challenging 6.
Hand function restoration remains the most challenging aspect of complete brachial plexus injury treatment, and patients should be counseled about realistic functional expectations 4.