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Health condition · Clinically reviewed

Brachial plexus injury, from motorcycle trauma to obstetric palsy - and what modern nerve surgery can restore.

Every plexus injury is different. Early specialist referral, careful imaging and modern nerve transfers make the biggest difference to what returns.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against BSSH, BOA and specialist plexus centre standards you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice on nerve transfers, MR neurography and specialist plexus MDT pathways.

Key facts

Brachial plexus injury at a glance.

The essentials, in plain English - what it is, why it happens, and how a UK plexus centre approaches it.

  • What it is

    Injury to the network of nerves (C5-T1) supplying the shoulder, arm and hand - traumatic, obstetric, inflammatory, iatrogenic, radiation, tumour or thoracic outlet in origin.

  • Adult traumatic

    Most often motorcycle accidents, high-energy road trauma, falls or penetrating injury - upper trunk (Erb), lower trunk (Klumpke) or global patterns.

  • Obstetric BPI

    1 to 3 in 1000 births, usually with shoulder dystocia or a large baby - around 90 percent recover spontaneously by 3 to 12 months.

  • Preganglionic

    Nerve root avulsion from the spinal cord - cannot be repaired directly and carries the worst prognosis. Horner sign and winging point to this pattern.

  • Postganglionic

    Rupture distal to the ganglion - can be reconstructed with nerve grafts and nerve transfers if referred early.

  • Timing matters

    Best outcomes when adult reconstruction happens within 3 to 6 months of injury - specialist plexus referral should not wait.

Why this guide matters

A time-critical injury with real options.

Brachial plexus injuries used to be considered untreatable. Modern nerve transfers, MR neurography and specialist rehab have changed the picture completely.

  • Time changes what is possible

    Adult reconstruction is best inside 3 to 6 months. Refer to a plexus centre early - do not wait for nerve studies alone.

  • Imaging tells you the pattern

    MR neurography and CT myelogram show root avulsion, rupture and where a nerve transfer can help.

  • Rehab is half the outcome

    Physio, hand therapy, orthotics and pain management shape function long after any surgery.

How the diagnosis is made

From the accident to a reconstruction plan.

The steps a UK plexus MDT will normally follow, in order - so you know what to expect and why timing matters.

  1. 01

    Assessing

    Early specialist referral

    Any suspected plexus injury should be discussed with a UK brachial plexus centre without delay - timing shapes what surgery is possible.

  2. 02

    Assessing

    History and mechanism

    Motorcycle crash, traction, penetrating wound, birth, cancer, radiotherapy or recent anaesthetic - each mechanism points to a different pattern.

  3. 03

    Assessing

    Full neurological examination

    BMRC power grading, dermatomal sensation, reflexes, Horner sign, rhomboid and serratus anterior testing and trophic changes.

  4. 04

    Confirming

    MRI and MR neurography

    Dedicated plexus protocol shows root avulsion (pseudomeningocele), rupture, neuroma and any compressing mass.

  5. 05

    Confirming

    CT myelogram if needed

    Gold standard for root avulsion where MRI is equivocal or contraindicated.

  6. 06

    Confirming

    Nerve conduction studies and EMG

    Delayed 3 to 6 weeks to allow Wallerian degeneration - localises the lesion and tracks reinnervation. Repeat at 3 to 6 months.

  7. 07

    Preparing

    Chest imaging and staging

    Chest X-ray and CT for Pancoast tumour, first rib fracture, diaphragm paralysis - obstetric cases use the Toronto or Narakas score and Active Movement Scale.

Typical timeline: specialist review within weeks, definitive surgery within 3 to 6 months where indicated.

Symptoms

What a brachial plexus injury feels like.

Weakness, altered sensation and pain in patterns that map onto the roots and trunks affected - and a handful of signs that point to the worst injuries.

  • Flaccid weakness

    A limp, powerless arm - the classic waiter tip posture with upper trunk (C5-C6) injury.

  • Sensory loss

    Numbness or altered feeling in a dermatomal pattern depending on which roots are involved.

  • Severe deafferentation pain

    Burning, crushing or electric pain, often worst in avulsion injuries and often out of keeping with the visible wound.

  • Horner sign

    Drooping eyelid, small pupil and reduced sweating on the same side - suggests T1 root avulsion.

  • Winged scapula

    Loss of rhomboid or serratus anterior points to a preganglionic (very proximal) injury.

  • Claw hand

    Lower trunk (C8-T1) Klumpke pattern - weak intrinsic hand muscles and long finger flexors.

  • Parsonage-Turner onset

    Sudden severe shoulder or arm pain followed days later by weakness - inflammatory neuralgic amyotrophy, often post-viral.

  • Red flag - Pancoast features

    Progressive lower trunk pain, Horner sign and weight loss in a smoker - urgent chest imaging for an apical lung tumour.

Treatment

How brachial plexus injury is treated in the UK.

Specialist MDT care, careful timing, modern nerve transfers and years of committed rehabilitation - with pain management running alongside.

  • Specialist plexus MDT

    Care led by a UK brachial plexus centre (Stanmore, Leeds, Newcastle, Bristol, Birmingham, Manchester, or paediatric centres such as Great Ormond Street and Alder Hey).

  • Observation in obstetric BPI

    Around 90 percent of babies recover by 3 to 12 months with physio and range-of-motion work - surgery considered if no biceps recovery by 3 to 6 months.

  • Early exploration

    Penetrating wounds, vascular injury and sharp lacerations may need urgent exploration and repair.

  • Nerve grafting

    Sural or medial cutaneous forearm grafts bridge a postganglionic rupture where healthy stumps remain.

  • Nerve transfers

    Oberlin, double fascicular, spinal accessory to suprascapular, phrenic, intercostal or contralateral C7 transfers restore key functions after avulsion.

  • Free functioning muscle transfer

    Gracilis transfer with its own nerve and blood supply to restore elbow flexion or finger movement in selected late cases.

  • Secondary reconstruction

    Tendon transfers, joint fusion (shoulder or wrist arthrodesis), elbow flexion procedures and prosthetics for late or incomplete recovery.

  • Neuropathic pain and rehab

    Gabapentin, pregabalin, amitriptyline or duloxetine, specialist pain clinic input, spinal cord stimulator or DREZ lesion for refractory avulsion pain - alongside intensive physio and OT.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your specialist plexus team knows your imaging and examination and can tell you which parts apply to you. If in doubt, get seen.

  • British Society for Surgery of the Hand (BSSH). Standards for brachial plexus surgery.

  • British Orthopaedic Association / BOAST guidance on peripheral nerve injury.

  • RCOG. Shoulder dystocia (Green-top Guideline No. 42).

  • NICE. Neuropathic pain in adults (CG173) and guidance on spinal cord stimulation (TA159).

  • Royal College of Anaesthetists. Peripheral nerve blocks and complications guidance.

Red flags

When brachial plexus injury needs urgent attention.

Some situations cannot wait for the standard pathway - these are the ones that need same-day surgical, oncological or paediatric review.

  • Vascular injury

    Expanding haematoma, absent pulse or a cold, pale limb after trauma - a vascular emergency alongside the nerve injury.

  • Open or penetrating wound

    Sharp lacerations, knife or gunshot injuries need urgent surgical exploration and, where possible, primary repair.

  • Progressive Pancoast features

    Worsening lower trunk pain, Horner sign and weight loss in a smoker - urgent chest imaging for an apical lung tumour.

  • Radiation plexopathy warning signs

    Progressive weakness or pain months or years after breast, lung or lymphoma radiotherapy - specialist review to distinguish recurrence from radiation injury.

  • No obstetric biceps by 3 months

    A newborn who is not flexing the elbow against gravity by 3 months needs prompt paediatric plexus referral.

  • Severe intractable pain

    Deafferentation pain unresponsive to first-line neuropathic medication - refer to specialist pain services early.

  • Parsonage-Turner suspicion

    Sudden severe shoulder pain followed by weakness after a viral illness, vaccination or surgery - needs neurology or plexus review.

  • Suspected iatrogenic injury

    New arm weakness or numbness after regional block, sternotomy or first rib resection - do not wait, seek specialist assessment.

  • Global flaccid arm after trauma

    A completely powerless, numb limb after high-energy trauma is a plexus emergency until proven otherwise.

Living with it

A long recovery, shaped by a strong team.

Four things that make the biggest difference month to month - staying with a specialist team, consistent therapy, treating pain early and using the support network around you.

A quiet reminder

Recovery is measured in months and years, not weeks.

Nerve regrowth is about a millimetre a day. Steady work over 12 to 24 months adds up to real function.

  1. 01 Team

    Stay in specialist care

    A plexus MDT - surgeons, therapists, pain specialists and psychologists - makes the difference over months and years of recovery.

  2. 02 Therapy

    Consistent physio and OT

    Daily range-of-motion work, splinting and hand therapy protect joints and prepare muscles for any reinnervation to come.

  3. 03 Pain

    Treat the pain early

    Neuropathic pain is part of the injury, not weakness. Early medication and pain clinic input are as important as the surgery.

  4. 04 Support

    You are not alone

    The Brachial Plexus Injury Association (BPIA) and paediatric groups connect people living with BPI and their families across the UK.

Frequently asked

Everything we get asked about brachial plexus injury.

Quick answers on Erb versus Klumpke, obstetric recovery, timing of surgery, imaging and pain control.

  • What is a brachial plexus injury?

    Damage to the network of nerves that runs from the neck (C5 to T1 spinal roots) through the shoulder to supply the arm and hand. It can follow trauma, birth, inflammation, surgery, radiotherapy, tumour or thoracic outlet compression, and it ranges from a temporary stretch (neurapraxia) to complete root avulsion from the spinal cord.

  • What is the difference between Erb and Klumpke palsy?

    Erb palsy affects the upper trunk (C5-C6) and gives the classic waiter tip posture - shoulder rotated in, elbow straight, forearm pronated. Klumpke palsy affects the lower trunk (C8-T1) and gives a claw hand with weak intrinsic hand muscles, often with a Horner sign if T1 is involved.

  • Will an obstetric brachial plexus injury recover on its own?

    About 90 percent of babies recover full or near-full function by 3 to 12 months with physiotherapy alone. If the biceps is not working against gravity by 3 to 6 months, specialist paediatric plexus centres such as Great Ormond Street, Alder Hey, Leeds, Bristol or Manchester consider primary nerve reconstruction.

  • How soon after a traumatic injury should I be seen?

    As soon as possible. Adult traumatic plexus injuries do best when reconstruction happens within 3 to 6 months, so early referral to a UK brachial plexus centre (Stanmore, Leeds, Newcastle, Bristol, Birmingham or Manchester) is essential - even before nerve conduction studies are complete.

  • What is the difference between preganglionic and postganglionic injuries?

    Preganglionic injuries are avulsions of the nerve root from the spinal cord and cannot be repaired directly - reconstruction depends on nerve transfers from other muscles. Postganglionic injuries are ruptures further out along the nerve and can often be bridged with nerve grafts. Horner sign, winging of the scapula and pseudomeningoceles on MRI all suggest a preganglionic pattern.

  • Can pain from a brachial plexus injury be controlled?

    Often, yes. First-line neuropathic drugs (gabapentin, pregabalin, amitriptyline, duloxetine) work for many people. Specialist pain input, spinal cord stimulation and, for refractory avulsion pain, a dorsal root entry zone (DREZ) lesion can help when standard treatment is not enough - always alongside physio, OT and psychological support.

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