Anatomy – Types of Injury

There is a range of injuries to the nerves (roots, trunks or divisions) that can be produces by traction.

A. Minimally stretched with no structural damage (neuraplexia).
In this injury the sensitive nerve fibres temporarily stop working but will rapidly recover without surgery.
B. Stretched but remains intact.
In this injury the nerve has been damaged but not torn apart. The nerves may recover to a variable degree on their own over a period of months and may not require surgical treatment
C. Nerve Rupture.
In this type of injury, the nerve has been stretched to breaking point and has been snapped or torn (similar to an overstretched elastic band). Ruptures will not heal without surgery.
D. Nerve Root Avulsion.
In this injury, the nerves are torn away from the spinal cord and cannot be re-joined to the cord. Some function of the arm will be permanently lost. At surgery, nerves may be transferred from other areas to improve function.

How do we establish what type of injury has occurred?

Initially you will be examined carefully to assess the movement and sensation you have in your arm. We may perform x-rays and scans (MRI scan, CT Scan) to help in the diagnosis and to exclude other injuries that are associated with brachial plexus injuries. Whilst these tests are useful to aid diagnosis, often the true extent of the injury may only finally be determined by performing an exploratory operation.

What treatment will I receive after the assessment?

A member of the team will discuss the results of all of the investigations with you and whether an operation is
necessary. If the injury to the brachial plexus is mild, and recovery is expected without surgery, then you will be seen in an outpatient clinic to help you with any problems that you may encounter with your arm, and to review your progress.

If it is clear that rupture or avulsion of the brachial plexus has occurred, then surgical exploration and repair of these nerves may be offered. If you have other more serious injuries, then the brachial plexus surgery may have to be delayed until these injuries are stabilised.

How are nerves repaired?

In clean cut injuries of nerves, each raw end of the nerve may be repaired (with the aid of an operating microscope) by re-attaching it to the other cut surface of the nerve. This end-to-end repair is usually not possible in the case of brachial plexus injuries, partly because the injury produces weakness at the shoulder muscles, which in turn allows the shoulder to droop consequently pulling the nerve ends apart. However, in the commonest injuries, the nerves are torn or stretched and the damaged segment of nerve either side of the rupture must be removed and repaired using grafts of nerves from the legs.

When nerves have been repaired, the nerve fibres then have to grow through the repair and out into the arm to the muscle or area of skin that they supply. These nerves grow very slowly and maximum recovery after nerve repair is lengthy. Furthermore, no nerve repair achieves complete recovery because of the impossibility of each individual microscopic nerve fibre reaching precisely and accurately the area it is best suited to supply.

What happens if I need surgery?

If you are not already on the plastic surgery ward, you will be given a date to come into hospital. When you arrive, you will be seen by the nursing staff, medical staff and anaesthetist. They will assess your health and this will also give you an opportunity to ask further questions.

The doctors will explain the operation again and will ask you to sign a form to say that you are willing for the operation for proceed. They may also draw a mark on the arm which is to be operated on.

You will not be allowed to eat or drink from the evening of the day before your operation. This is to prevent you being sick when you go to sleep during a general anaesthetic.

On the morning of the operation, you will be given a gown to wear and you may have some medicine to make you feel drowsy before a nurse and porter take you to theatre. In the theatre, you will be met by the nursing staff and the anaesthetist.

The Operation

All surgery is performed under general anaesthetic. The surgeon will examine the nerves to establish the extent of the damage and whether repair is possible. If they find that the nerves have been ruptured (separated) then the gap between the nerves will be bridged by a nerve graft. These grafts may be taken from less important sensory nerves on the back of the legs (sural nerves) or from nerves in the injured arm. These nerve grafts will act as guides through which new nerve fibres can grow and cross the gap caused by the injury, to reach the muscles and sensory receptors of the shoulder, arm and hand.

If the nerves have been avulsed, it is impossible at present to re-attach the nerves to the spinal cord (although research into this area continues). To try and regain function within the arm, intact nerves nearby doing less valuable jobs can be transferred to parts of the brachial plexus. The transferred nerves no longer allow their original, less important, movements but the signals they carry can be used to make the more important muscles of the shoulder and arm work.

Commonly transferred nerves include the nerve that normally shrugs the shoulder (accessory nerve) and nerves from the chest that supply the muscles between the ribs (intercostal nerves) which are transferred to muscles involved in stabilising the shoulder and moving the elbow.

When these nerves start to recover, you will need to work very hard at retraining these nerves to move your arm and initially you may have to do different movements to make your arm work.

What will I be like when I return from theatre?

. You will feel tired until the effects of the anaesthetic wear off.
. If you have any pain after your operation, it is important that you let the nurses know so that they may give you
medication to help ease any pain.
. You will have stitches or surgical clips on your neck and the back of your legs (if sural nerve grafts are used).
These will be covered with dressings.
. You will have your arm strapped to your side or in a sling and this must stay in place for four weeks. It is
extremely important that you do not remove this tape or sling as even a brief movement of your arm away from
your body can damage the repair to your nerves.
. You may have a drain in place to remove fluid from around the wound. This will usually be taken out after a few

How long will I have to stay in hospital?

Following your brachial plexus surgery, you should only stay on the ward for a few days. This is dependent upon any other injuries you may have sustained at the time of your accident.

What follow up will I have?

One week following your operation;

. You will attend the dressing clinic and have your tape changed. at this stage any stitches that you have may be
removed and your wound, arm and armpit cleaned.
. We will re-tape your arm.

Four weeks following your operation;

. You will be seen in the dressing clinic four weeks after your surgery to have the strapping or sling removed.
. You will see the physiotherapist to start passive exercises on your arm.
. You may see the occupational therapist to assess how you are managing with activities of daily living (ADL).

Three months following your operation;

. You will be seen in a multi-disciplinary team clinic. This will allow you to discuss with the team how you are
managing following your injury. Following this, your progress will be monitored regularly in a brachial plexus
practitioner clinic, by a specialist physiotherapist. There may be a need to have an additional operation in the
future and this will be discussed with your consultant at this stage.

Can I have a bath or shower?

If you have not had nerve grafts taken from your legs, then as long as you do not get the dressing wet on your arm, you can have a shallow bath.

What happens if my dressings get wet?

If your dressings get wet then please phone either the dressing clinic (08:30-16:30 Monday to Friday), or the ward (16:30-08:30 Monday to Friday and weekends). (This applies to Leeds General Hospital). They will be able to advise you on what to do.

What happens if I am worried about my wound?

If you are concerned about your wounds, then please phone either the dressing clinic (08:30-16:30 Monday to Friday) or the ward (16:30-08:30 Monday to Friday and weekends). (This applies to Leeds General Hospital) They will be able to advise you on what to do.

When can I return to work?

This depends on your job and also on the extent of your injury, and you will need to discuss this with any of the brachial plexus team. After the strapping is removed at four weeks, you are unlikely to do any harm to your plexus or to the surgery that has been performed. However, the movement and sensation of your arm will be the same as it was immediately before the operation. This is a result of the length of time it takes for the nerves to grow.

If you are unable to return to your previous job, of your employer is unable to provide alternative work, there are a number of supportive organisations that you can contact, which are listed under Other Organisations below.

When can I return to sports and hobbies?

This will depend on your injury and also the sport or hobby you wish to return to. You will need to discuss this with a member of the medical team.

How long will it take for nerves to recover?

New nerves have to grow from the neck, down the brachial plexus, past the injury site and through the nerves into the upper limb in order to reach the muscles and sensory receptors. Nerves grow at an average of 1mm per day but will take longer to grow through the nerve grafts and across the sites of repair.

As the nerve starts to recover, you will initially get a twitch of your muscle. At this stage, you will be informed of how to strengthen this muscle by the physiotherapists. Recovery of your nerves and the rehabilitation of your arm can take from several months to several years.