Case 62 Adult Brachial Plexus Injury

Timothy Fei and Kyle Chepla

Case 62 Adult Brachial Plexus Injury

Case 62 A 32-year-old right-hand-dominant male was involved in a high-speed motorcycle crash 3 months ago. He subsequently developed left-sided unilateral loss of sensation, shoulder weakness, and inability to flex his elbow.

62.1 Description

  • Unilateral loss of upper extremity sensation with biceps and shoulder weakness after high-energy injury and concern for upper brachial plexus injury (C5–C6)

  • Clinical photograph demonstrates left-sided wasting of the deltoid and biceps with preserved triceps and wrist extensors; patient is unable to abduct and externally rotate his shoulder or flex his elbow

62.2 Work-Up

62.2.1 History

  • Mechanism of injury: Penetrating (e.g., sharp laceration or gunshot) versus traction; high-energy versus low-energy injury

  • Time since the injury occurred

  • Age and hand dominance

  • Occupation and hobbies

  • Previous upper extremity injury or surgery

  • Any previous work-up of the injury

62.2.2 Physical Examination

  • Critical to take a full inventory of sensory and motor deficits

    • Localizes level of injury and helps in guiding treatment plan

  • Evaluate and grade motor function: British Medical Research Council (MRC) scale for muscle strength (see Table 62-1) of all muscles innervated by the brachial plexus (see Fig. 62-1)

  • Evaluate sensory function: Dermatome distribution and two-point discrimination (2PD) in fingers

  • Joint mobility: Passive range of motion at shoulder, elbow, wrist, hand, and fingers

  • Vascular status: Pulses and capillary refill to evaluate for associated arterial injury (10–25% incidence)

  • Evaluate for Horner’s syndrome (ptosis, anhidrosis, and miosis) which indicates a preganglionic injury involving the sympathetic chain

  • Assess for common associated bony fractures: Cervical fracture, clavicle fracture, rib fracture, scapula fracture, and shoulder dislocation

    Fig. 62.1 Brachial plexus anatomy. For reference (do not memorize).

Table 62.1 British Medical Research Council Motor Grading Scale


Exam findings


No muscle contraction


Visible muscle contraction, but no movement


Visible muscle contraction, active movement in plane, with gravity eliminated


Active movement against gravity, but not against resistance


Active movement against strong resistance, but not full strength


Active movement, with full strength

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 62 Adult Brachial Plexus Injury
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