For brachial plexus patients with extensive and/or severe disorders, surgery for nerve reconstruction may be an option, usually occurring between 3-9 months after onset. The goal of nerve surgery is not to regain a normal arm. Instead, primary nerve reconstruction is a step towards a functional arm with adequate movement for activities of daily living. Nerve graft repair and/or nerve transfer are the primary options for reconstructing the brachial plexus. Nerve regeneration is very slow, so the ultimate functional outcome from nerve reconstruction surgery may not be apparent for 1-3 years. For associated musculoskeletal abnormalities, clinical function and radiographic imaging can guide the decision to pursue further orthopedic or plastic/hand surgery intervention: internal rotation contractures of the shoulder are very common and can be associated with progressive glenohumeral joint deformity and shoulder joint instability. Surgical options include muscle lengthening with or without tendon transfers, corrective osteotomies, and/or open or arthroscopic reduction of the shoulder joint. For patients with residual elbow, forearm, and hand problems, secondary procedures by a hand surgeon may help function: these procedures include soft tissue releases, joint fusions, muscle transfers, and corrective osteotomies. Secondary reconstruction of shoulder or elbow/forearm function can occur years after injury or when needed. For all surgical interventions, the most important factor in producing the optimal result is a cooperative patient with intense support from assertive families.
Medical Management and Rehabilitation
The diagnosis of brachial plexus injury should be confirmed by a specialist. In the early days after injury, any associated skeletal injuries or fractures should be confirmed by clinical and radiographic evaluation since these injuries may preclude early occupational/physical therapy. No substantial evidence exists to support further injury to the brachial plexus with gentle handling of the neck and affected arm, and immobilization of the arm is not recommended except in the context of skeletal injuries. Other neurologic disorders occurring concurrently with brachial plexus injury, can be suspected with the presence of a lack of spontaneous movements and normal reflexes that suggest more global neurological deficits. Alternatively, an observed asymmetric expansion of the chest cavity and difficulty with breathing can suggest diaphragmatic palsy resulting from associated phrenic nerve injury, confirmed with plain X-rays or ultrasonography. The passive and active range of motion of the affected arm should be assessed. Supplementing the physical examination with electrodiagnostic (EDX) and radiographic (magnetic resonance imaging, MRI, ultrasound, CT) findings are helpful to decide whether surgery will be beneficial or whether the disorder should be managed conservatively.