New York State Medical Treatment Guidelines for
Brachial Plexus Injuries in workers compensation patients

The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Brachial Plexus Injuries.

These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders. The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.

Brachial Plexus Injuries of Shoulder Injury

Injuries to the brachial plexus cause discomfort, instability of the shoulder, and loss of motor and sensory function in the shoulder girdle area. The mechanism of injury, as well as the type and degree of brain involvement, all influence signs and symptoms.

Acute direct trauma and repeated motion or overuse are the two damage mechanisms. Sensory and motor symptoms brought on by brief compression, stretch, or traction (neuropraxia) continue for days to weeks. Similar symptoms may result from axonotmesis, which damages the axon without affecting the nerve’s structural integrity. Axon regeneration far from the site of injury determines how long it takes for healing to occur.

The most severe type of nerve injury is laceration or disruption of the entire nerve with total loss of the framework (axonotmesis).Regrowth of the nerve far from the site of the lesion is necessary for function to return, although complete axon sheath destruction may make recovery more difficult.

The most used diagnostic method for examining nerve damage is electrodiagnostic tests (EDX). When necessary, these studies should be used to supplement the clinical examination and history.

Demyelination-related slowing of motor nerve conduction velocities can be localised to pinpoint damage and entrapment sites. The electromyographic denervation shown there is a sign of motor axonal or anterior horn cell loss.

Three to four weeks after an accident or the description of symptoms, studies should be conducted. Studies may be carried out right away following the initial examination (defined as the first interaction with the doctor, not the date of damage) if the symptoms have been present for more than three to four weeks.

If initial examinations are negative, serial studies may be advised. They may also be helpful for determining prognosis. The temperature of the limb affects the speed of nerve conduction.

When significant slowing of conduction is seen, the American Association of Neuromuscular and Electrodiagnostic Medicine’s (AANEM) standard, which includes temperatures, should be adhered to. Physicians board qualified in neurology or physical medicine and rehabilitation are encouraged to perform and interpret EDX in the outpatient setting.

There are six shoulder girdle nerve injuries that are relatively common. We’ll talk about each kind separately.

The nerve roots of C5–C8 and T1 combine to produce the brachial plexus. These nerve roots leave the cervical spine through the scalene muscles, and then, at the level of the clavicle, they form trunks, divisions, and chords that eventually give rise to the arm’s peripheral nerves.

History and Mechanism of Brachial Plexus Injuries

Widespread sensory and motor loss results from direct brachial plexus damage. Direct trauma, subluxation of the shoulder, clavicular fractures, shoulder depression, and head deviation away from the arm may result in variable brachial plexus lesions.

It is important to differentiate injuries to the brachial plexus from the acquired (nonwork-related) syndrome of brachial plexus neuritis, Parsonage-Turner Syndrome.

Physical Findings may include

• Examination to look for signs of trauma or malformation;
• Identification of sensory loss and evidence of weakness related to the nature and extent of the brachial plexus damage; or
• Pain when performing the same movements that caused the injury.

Laboratory Tests of Brachial Plexus Injuries

Laboratory Tests of Brachial Plexus Injuries are recommended when a suspected systemic disease or ailment is seen in a subset of people.

Testing Procedures of Brachial Plexus Injuries

Electrodiagnostic investigations may be used as testing procedures (EDX). If they are unable to localise and provide adequate information, MRI and/or myelography may be used to get more data.

These examinations are used to distinguish between severe brachial plexus injuries and root avulsion. An apical lordotic chest x-ray may be used in the evaluation of brachial plexus.

Non-Operative Treatment Procedures (Brachial Plexus):

• Observation is preferred in closed injuries; subsequent electrodiagnostic testing may be useful to track healing. In cases of mild to severe presentations, a sling may be necessary.
• Rehabilitation using the non-operative therapeutic treatments described in Section E.
• Steroids may also be administered to lessen the inflammatory response, along with analgesics, nonsteroidal anti-inflammatories, antidepressants, and anticonvulsants (such as gabapentin). Narcotics may have a short-term acute indication and should be prescribed as needed.
• Operative Procedures (Brachial Plexus): For open injuries, exploration may be necessary if a conservative strategy fails to improve healing; for closed injuries, exploration is also necessary if progressive weakness and loss of function are seen after 4-6 months of conservative therapy.
• A personalised rehabilitation programme built on collaboration between the doctor, surgeon, and therapist would be included in post-operative procedures (brachial plexus).

  This programme would start with four to six weeks of rest, then gradually build range of motion and strength.

Axillary Nerve of Brachial Plexus Injuries

The fifth and sixth cervical roots are the source of the axillary nerve. The lateral side of the proximal arm receives sensation at the level of the deltoid as it goes around the shoulder and provides motor branches to the teres minor and the three heads of the deltoid.

History and Mechanism of Axillary Nerve

The axillary nerve can be injured by direct trauma to the shoulder, penetrating wounds, and upward pressure on the axilla. Nerve injuries are also possible with fractures of the surgical neck of the humerus and shoulder dislocation. Finally, shoulder surgery by itself can demonstrate axillary nerve damage.

• The deltoid muscle is weakened and shrinking;
• Abstraction, flexion, and extension of the shoulder result in a loss of strength; alternatively,
• Over the top of the arm, there is sensory loss.

Laboratory Tests of Axillary Nerve

Laboratory Tests of Axillary Nerve are recommended when a systemic illness or disease is suspected in a subset of patients.

Testing Procedures of Axillary Nerve

Testing Procedures of Axillary Nerve are recommended clinically appropriate in a subset of patients.

Indications: for people who have enduring symptoms.

Non-Operative Treatment Procedures of Axillary Nerve

• Using the techniques outlined in Section E, Therapeutic Procedures: Non-Operative.
• Medications like opioids may only occasionally be indicated initially, along with analgesics, nonsteroidal anti-inflammatories, antidepressants, and anticonvulsants.

Operative Procedures

Since traction and/or strain are the main causes of axillary nerve injury, surgical procedures are typically not required.

Testing Procedures of Axillary Nerve

Testing Procedures of Axillary Nerve are recommended clinically appropriate in a subset of patients.

Indications: After four to six months, if electrodiagnostic testing shows continued innervation and function loss, surgery may be considered.

Post-Operative Procedures of Axillary Nerve
A personalised rehabilitation programme built on collaboration between the doctor, the surgeon, and the therapist would be part of post-operative procedures. Four to six weeks of relaxation would be followed by a gradual increase in motion and strength to start this programme.

Long Thoracic Nerve of Brachial Plexus Injuries

The cervical fifth, sixth, and seventh roots combine to produce the long thoracic nerve, which descends along the back of the thoracic wall to the stratus anterior after crossing the first rib’s boundary.

History and Mechanism of Injury of Long Thoracic Nerve

Direct trauma to the neck’s posterior triangle can result in injury, as can forceful shoulder depression that is repeated or chronically applied repeatedly. Long thoracic nerve dysfunction can be caused by repeatedly moving the arms forward, stretching or compressing the nerve while the arms are abducted, or both.

Physical Findings (Long Thoracic Nerve) may include:

• Dull pain in the shoulder area without any sensory loss;
• The patient or family member may describe scapular deformity and/or winging; and/or
• By asking the patient to flex and lean on their arms, say, against a wall, and/or the examiner preventing protraction, the Serratus Anterior (scapular winging) can be demonstrated.

Laboratory Tests of Long Thoracic Nerve

Laboratory Tests of Long Thoracic Nerve are recommended when a systemic illness or disease is suspected in a subset of patients.

Testing Procedures of Long Thoracic Nerve

Testing Procedures of Long Thoracic Nerve are recommended clinically appropriate in a subset of patients.

Indications: Electrodiagnostic examinations are utilised to clarify the anatomy and degree of the injury when signs or symptoms are persistent; side-by-side comparisons of the nerve might be helpful to confirm the diagnosis.

Research may also rule out more pervasive brachial plexus involvement.

Non-Operative Procedures of Long Thoracic Nerve

• Using the techniques outlined in Section E, Therapeutic Procedures: NonOperative.
• Analgesics, nonsteroidal anti-inflammatories, antidepressants, and anticonvulsants may all be necessary, and opioids may also be critically necessary in rare circumstances.

Operative Procedures

Non-Operative Procedures of Long Thoracic Nerve

Non-Operative Procedures of Long Thoracic Nerve are recommended in a small number of individuals when clinically necessary

Indications: Only in the most extreme circumstances, where there has been a considerable loss of function that has been medically documented, may operative procedures like scapular fixation be advised.

Post-Operative Procedures of Long Thoracic Nerve

A personalised rehabilitation programme built on collaboration between the doctor, the surgeon, and the therapist would be part of post-operative procedures. Eight to ten weeks of relaxation would be followed by a gradual increase in motion and strength to start this programme.

Musculocutaneous Nerve of Brachial Plexus Injuries

The coracobrachialis, biceps, and brachialis muscles are innervated by the musculocutaneous nerve, which is derived from the fifth and sixth cervical roots. It also provides feeling to the lateral aspect of the forearm. Nerve damage can frequently result from trauma (including surgery) or penetrating wounds to the brachial plexus, coracobrachialis, and shoulder.

History and Mechanism of Injury of Musculocutaneous Nerve

Mechanism of Damage: The most frequent type of injury is a stretch or traction injury brought on by a forceful elbow extension that causes nerve dysfunction; trauma can be evident to the sensory component (lateral antebrachial cutaneous nerve), which denotes a loss of forearm sensation.

Physical Findings of Musculocutaneous Nerve

Pain in the arm;

• Biceps and brachialis biceps are weak and atrophying; furthermore
• Sensory loss on the forearm’s lateral side, albeit this is not always evident.
• Biceps deep tendon reflex attenuation or loss.

Laboratory Tests of Musculocutaneous Nerve

Laboratory Tests of Musculocutaneous Nerve are recommended when a systemic illness or disease is suspected in a subset of patients.

Testing Procedures of Musculocutaneous Nerve

Testing Procedures of Musculocutaneous Nerve are recommended clinically appropriate in a subset of patients.

Indications: Among the testing methods are electrodiagnostic investigations done when symptoms or indicators are persistent; side to side similarities between the sensory and motor parts of The nerve may be helpful given that conventional norms are not always dependable

Non-Operative Treatment Procedures of Musculocutaneous Nerve

• Using the techniques outlined in Section E, Therapeutic Procedures: Non-Operative.
• It may be necessary to take medications including analgesics, nonsteroidal anti-inflammatory drugs, antidepressants, and anticonvulsants. Rarely, it may be necessary to use narcotics.

Operative Procedures of Musculocutaneous Nerve are recommended clinically appropriate in a subset of patients.

Indications: Unless there has been a progressive loss of function over four to six months and/or a nerve laceration has been found, surgical procedures are typically not required.

Physical Findings of Musculocutaneous Nerve
A personalised rehabilitation programme built on collaboration between the doctor, the surgeon, and the therapist would be part of post-operative procedures. Eight to ten weeks of relaxation would be followed by a gradual increase in motion and strength to start this programme.

Spinal Accessory Nerve of Brachial Plexus Injuries

Spinal Device The ipsilateral sternocleidomastoid and trapezius muscles, which are crucial for scapular control and, ultimately, shoulder function, are innervated by Nerve, the eleventh cranial nerve.

History and Mechanism of Injury (Spinal Accessory Nerve)

History and Mechanism of Injury (Spinal Accessory Nerve) are recommended in select patients as clinically indicated.

Physical Findings may include:

• The shoulder hurts;
• Abduction, which is perceived as winging with the arms out to the side due to trapezius weakness or paralysis, and/or
• Shoulders that have sagged.

Laboratory Tests of Spinal Accessory Nerve are recommended – When a systemic illness or disease is suspected in a subset of patients.

Testing Procedures of Spinal Accessory Nerve are recommended– Clinically appropriate in a subset of patients.

Indications: Electrodiagnostic tests are a part of testing procedures when signs and symptoms are persistent. In order to determine the anatomy and extent of the injury, electrodiagnostic studies are used. Side-to-side comparisons of the nerve can also be useful in confirming the diagnosis. Finally, radiographic procedures may be required in order to rule out lesions at the base of the brain or in the upper cervical spine.

Non-Operative Treatment Procedures of Spinal Accessory Nerve

• Rehabilitation using the non-operative therapeutic treatments described in Section E.
• Narcotics may occasionally be acutely indicated, as can medications including analgesics, nonsteroidal anti-inflammatories, antidepressants, and anticonvulsants.

Operative Procedures of Spinal Accessory Nerve are recommended – clinically appropriate in a subset of patients.

Indications: Unless a proven progressive loss of function over four to six months and/or an identifiable nerve laceration are present, surgical procedures are typically not required.

Post-Operative Procedures of Spinal Accessory Nerve

A personalised rehabilitation programme built on collaboration between the doctor, the surgeon, and the therapist would be part of post-operative procedures. Eight to ten weeks of relaxation would be followed by a gradual increase in motion and strength to start this programme.

Suprascapular Nerve of Brachial Plexus Injuries

The supraspinatus and infraspinatus muscles of the rotator cuff are innervated by the suprascapular nerve, which originates from the fifth and sixth cervical roots and superior trunk of the brachial plexus.

History and Mechanism of Injury for Suprascapular Nerve
Mechanism of Injury: Injury to the supraclavicular nerve can result from trauma, stretching, or friction through the suprascapular notch or against the transverse ligament at the notch; on occasion, it has been demonstrated that repetitive use of the arm can traction the nerve.

Physical Findings of Suprascapular Nerve
Pain at the shoulder; Wasting effort with weakened infraspinatus and/or supraspinatus muscles; and/or Tinel’s can aid in provoking a pain response.

Laboratory Tests of Suprascapular Nerve

Laboratory Tests of Suprascapular Nerve are recommended when a systemic illness or disease is suspected in a subset of patients.

Testing Procedures of Suprascapular Nerve

Testing Procedures of Suprascapular Nerve are recommended clinically appropriate in a subset of patients.

Indications: Electrodiagnostic tests are a part of testing procedures when signs and symptoms are persistent. Since established norms are not always trustworthy, side-by-side comparisons may be helpful. An MRI may be necessary if there is a mass lesion at the suprascapular notch.

Non-Operative Treatment Procedures of Suprascapular Nerve

• Using the techniques outlined in Section E, Therapeutic Procedures: Non-Operative.
• Narcotics may occasionally be acutely indicated, as can medications including analgesics, nonsteroidal anti-inflammatories, antidepressants, and anticonvulsants.

Operative Treatment Procedures of Suprascapular Nerve

Operative Treatment Procedures of Suprascapular Nerve are recommended clinically appropriate in a subset of patients.

Indications: Depending on the electrodiagnostic study results and/or the lack of improvement with conservative management, surgical release at the suprascapular notch or spinoglenoid region is warranted.

Post-Operative Procedures of Suprascapular Nerve

A specific post-operative plan would be part of the procedures. approach of rehabilitation based on dialogue between a doctor, a surgeon, and a therapist.An eight to ten week period of rest would be followed by a gradual increase in motion and strength as part of this regimen.

What our office can do if you have Brachial Plexus Injuries

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