Q2 LONG ANSWER 10M ★ High-yield

Describe Brachial Plexus Injuries in detail.

General Surgery · Final Professional

Definition & Anatomy

The brachial plexus is the network of nerves (roots C5–T1) that supplies the upper limb, organised into roots → trunks → divisions → cords → branches. Brachial plexus injuries usually follow high-energy traction (motorcycle accidents forcing the head and shoulder apart), birth injury, penetrating trauma or traction during surgery, and cause varying patterns of upper-limb paralysis and sensory loss.

Organisation of the brachial plexus from roots to terminal branches (mnemonic: Roots, Trunks, Divisions, Cords, Branches).

Patterns of Injury

Upper plexus (Erb’s, C5–C6) — from widening of the head–shoulder angle
the arm hangs in the ‘waiter’s tip’ position (adducted, internally rotated, extended elbow, pronated), the hand being spared.
Lower plexus (Klumpke’s, C8–T1) — from forced abduction of the arm
affects the intrinsic hand muscles (claw hand) and may show a Horner’s syndrome.
Total (whole plexus) palsy gives a flail, anaesthetic limb.

DANGER / REMEMBER

A preganglionic (root avulsion) injury — suggested by a Horner’s syndrome, winging of the scapula, or avulsion on imaging — cannot be repaired directly and has a poor prognosis, whereas a postganglionic rupture may be grafted. Distinguishing the two is central to planning.

Clinical Assessment & Investigations

A careful neurological examination maps the level and completeness of the lesion (motor power, sensation, reflexes, Horner’s sign). Nerve conduction studies/EMG (after a few weeks) and MRI / CT myelography assess root avulsion versus rupture. Associated vascular and bony injuries are excluded.

Management

Many obstetric and traction (neurapraxic) injuries recover spontaneously and are managed with physiotherapy to maintain a supple limb while awaiting recovery. Surgery is considered when there is no recovery within the expected window: options include nerve repair, nerve grafting and nerve transfers (neurotisation) for suitable lesions, and later reconstructive procedures (tendon/muscle transfers, arthrodesis, free muscle transfer) to restore key functions such as elbow flexion. Realistic goals and rehabilitation are essential.

CLINICAL PEARL

Erb’s (upper, C5–C6) = waiter’s tip, hand spared, better prognosis; Klumpke’s (lower, C8–T1) = claw hand ± Horner’s, worse. A Horner’s syndrome flags a preganglionic root avulsion.

Complications & Prognosis

The prognosis depends chiefly on the level and type of injury: neurapraxic and postganglionic lesions may recover well, whereas preganglionic root avulsions have a poor outlook and denervated muscle that is not re-innervated within roughly 18–24 months becomes irreversibly fibrotic. Complications include a flail, insensate limb, disabling neuropathic pain (particularly with avulsions), joint contractures, and — in the anaesthetic hand — unnoticed injuries and trophic changes. Realistic goal-setting, pain management and sustained rehabilitation are as important as the reconstructive surgery.

Injury	Roots	Deficit
Erb-Duchenne	C5–C6	Waiter tip — shoulder abduction, elbow flexion lost
Klumpke	C8–T1	Claw hand, intrinsic muscles; ± Horner syndrome
Total plexus	C5–T1	Flail anaesthetic limb
Preganglionic clue	—	Horner syndrome, winged scapula — poor prognosis

KEY POINT

Key points TO remember

Roots C5–T1 → trunks → divisions → cords → branches; injured by traction.
Erb’s (C5–C6): waiter’s tip, hand spared. Klumpke’s (C8–T1): claw hand ± Horner’s.
Preganglionic avulsion (Horner’s, winged scapula) = poor prognosis, not directly repairable.
MRI/CT myelography + EMG distinguish avulsion from rupture.
Physiotherapy while awaiting recovery; nerve grafts/transfers then reconstruction if no recovery.

EXAM TIP

Sources: Maheshwari's Essential Orthopaedics; Apley & Solomon's System of Orthopaedics and Trauma; AO Principles of Fracture Management.

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