Brachial Plexus

Brachial plexus injuries represent some of the most complex and life-altering nerve injuries in reconstructive surgery. The brachial plexus — a network of nerves originating from the cervical and upper thoracic spine — controls virtually all movement and sensation in the shoulder, arm, and hand. When disrupted by traction trauma (most commonly in road traffic accidents or birth injuries), the consequences can range from temporary weakness to complete, permanent paralysis of the entire upper limb.

At Olive Skin & Aesthetics, we manage traumatic and obstetric brachial plexus injuries with a structured, evidence-based approach — from early nerve exploration and repair to neurotisation (nerve transfer), free functional muscle transfer, and late tendon transfer procedures — always prioritising the recovery of the most functionally important movements: shoulder abduction, elbow flexion, and hand function.

• Adults and children with traumatic brachial plexus injuries — typically from motorcycle accidents, falls from height, or sports injuries
• Infants with obstetric brachial plexus palsy (Erb’s palsy or Klumpke’s palsy) who fail to recover spontaneously by 3 months of age
• Patients with partial plexus injuries (upper, lower, or combined trunk lesions)
• Individuals presenting in a delayed manner where nerve repair is no longer viable and nerve or tendon transfer is the appropriate strategy
• Patients who have undergone primary repair elsewhere and require secondary procedures to improve residual functional deficits

The management pathway is determined by the severity and level of the injury, defined by clinical examination and supported by MRI, CT myelogram, and nerve conduction studies. Surgery is ideally performed within 3–6 months of injury for traumatic cases, and by 3–6 months of age for birth injuries that do not show adequate spontaneous recovery.

Root avulsions (where the nerve is torn from the spinal cord) cannot be directly repaired and require neurotisation — using expendable donor nerves such as the intercostal nerves, phrenic nerve, or contralateral C7 — to reinnervate priority muscles (biceps for elbow flexion, deltoid for shoulder abduction). Root ruptures (where continuity is preserved but the nerve is torn outside the cord) are repaired with nerve grafts harvested from the sural nerve.

Late reconstructions — for patients presenting beyond the window for nerve repair — use tendon transfers, free functional muscle transfers (gracilis muscle), and arthrodesis to restore the most critical upper limb functions.

• Days 1–5 (hospital): Arm supported in sling. Wound and drain management. Early physiotherapy for shoulder and elbow positioning.
• Week 2–6: Structured physiotherapy commenced — passive range of motion for all joints to prevent stiffness during the nerve regeneration wait.
• Month 3–6: Early signs of reinnervation monitored clinically (Tinel’s sign, EMG). Physiotherapy intensified.
• Month 6–12: Motor recovery, where it occurs, becomes clinically detectable. Strength grading and functional assessment guide next steps.
• Month 12–24: Maximum spontaneous recovery assessed. Secondary procedures (tendon transfers, muscle transfers) planned if residual deficits warrant intervention.
• Ongoing: Long-term physiotherapy and occupational therapy. Psychological support for adaptation to residual disability where applicable.