What is the recommended therapy and timeline for managing a brachial plexus injury?

Brachial Plexus Injury Therapy

For brachial plexus injuries, initiate physical therapy immediately to maintain range of motion while pursuing MRI evaluation at approximately 1 month post-injury, with surgical intervention required within 6 months for optimal outcomes in cases of complete nerve rupture or root avulsion. 1, 2, 3

Immediate Management (First 4 Weeks)

• Begin physical therapy immediately after injury to prevent joint contractures and maintain passive range of motion, even before definitive diagnosis is established 4
• Delay imaging until approximately 1 month post-trauma to allow hemorrhage and edema resolution and permit pseudomeningocele formation for accurate diagnosis 5, 1, 6
• Perform electrodiagnostic studies (EMG/NCS) to assess severity and location of nerve injury 1

Diagnostic Timeline (3-4 Weeks Post-Injury)

• Obtain MRI of the brachial plexus with dedicated protocol (not standard neck/spine MRI) as the gold standard imaging modality 1, 7, 6
• The critical diagnostic determination is whether injury is preganglionic (root avulsion) versus postganglionic, as this fundamentally changes surgical approach and prognosis 5, 1
• Determine if nerve is completely ruptured (requiring early surgery) versus stretched but intact (may recover spontaneously) 1, 7

Surgical Timing Based on Injury Type

Immediate Surgical Exploration Required:

• Penetrating or open injuries 1, 7
• Clinical or imaging evidence of at least one root avulsion 3
• Subclavian artery damage 3
• Complete (total-type) brachial plexus injury 3

Conservative Management for 3 Months:

• Upper trunk injuries without preganglionic lesion signs can be observed for 3 months 3
• If no clinical recovery signs appear by 3 months, proceed to surgical exploration 3

Optimal Surgical Window:

• Surgery within 6 months of injury yields favorable outcomes for restoring shoulder and elbow function 2, 3
• Best results for intercostal nerve transfer occur in patients under 30 years operated within 6 months 3

Surgical Techniques by Functional Goal

For Elbow Flexion Restoration:

• The Oberlin procedure (nerve transfer) is significantly more successful than nerve grafting or combined techniques 8
• Intercostal nerve transfer achieves greater than M3 (Medical Research Council grade 3) elbow flexion in 70% of patients with root avulsion 3
• Free functional muscle transfer is indicated when patients present more than 12 months post-injury or when primary reconstruction fails 9

For Shoulder Abduction:

• Nerve transfer techniques are significantly more successful than nerve grafting for shoulder abduction 8
• Nerve grafting achieves greater than M3 power in infraspinatus (70% of patients) and deltoid (70% of patients) when exploration extends distally 3

For Hand Function:

• Hand function restoration remains the most challenging aspect of complete brachial plexus injury 2
• Nerve grafting for forearm muscles yields poor results 3
• Intercostal nerve transfer can restore protective sensation in median nerve distribution but motor recovery is poor 3

Rehabilitation Protocol

• Early and long-lasting rehabilitation is essential due to severe chronic impairments 4
• Address multifaceted clinical picture including pain, muscle atrophy, weakness, and secondary deformities 4
• Incorporate interdisciplinary team including hand therapists, pain management specialists, and mental health experts to address psychological problems and patient cooperation issues 2, 4
• Continue therapy throughout the lengthy recovery process to prevent central nervous system reorganization and upper limb underuse 4

Common Pitfalls to Avoid

• Do not use standard neck, chest, or spine MRI protocols—specialized brachial plexus protocols with orthogonal views through oblique planes are mandatory 1, 6
• Do not delay surgical intervention beyond 6 months in cases requiring operative management, as outcomes deteriorate significantly 2, 3
• Do not assume cervical spine MRI adequately evaluates the plexus, as it only visualizes nerve roots within neural foramina 6
• Do not neglect psychological support and pain management, as these factors significantly impact rehabilitation effectiveness and disability 4