Clinical Pilates in Practice: Brachial Plexus Injury After Shoulder Dislocation

This literature review examined the neurological implications of shoulder dislocation. The authors analyzed the implications of brachial plexus injury, the incidence of neurological injuries in patients with shoulder dislocation, and proposed the algorithm for management.

Olga G et al. Brachial Plexus Injury After Shoulder Dislocation: A Literature Review. Neurosurgical Review (2020) 43:407–423. https://doi.org/10.1007/s10143-018-1001-x

Key Points: Brachial Plexus Injury

• Traumatic anterior shoulder dislocation has an incidence estimated of 2% across the population.

• 4-55% incidence of neurological complications after dislocations is reported in the literature.

• Neurological complications are more prevalent with primary vs recurrent dislocations.

• Brachial plexus injury (BPI) after dislocation is generally observed in two groups:

  → Dislocation from high energy impact (most often an MVA).

  → Dislocation from a fall (typically with no accompanying fractures).

• BPI is more prevalent in populations sustaining a shoulder dislocation post-fall.

• Neurological complications of shoulder dislocation include single nerve injuries and complex brachial plexus injuries.

• Brachial plexus injury after shoulder dislocation is common among two patient groups:

  → Patients whose dislocation as the result of high-energy forces.

  → Patients with shoulder dislocation as the result of a simple fall.

• Shoulder dislocation damages neural structures via different mechanisms:

  → Crushing of the nerve between the humeral head and the axillary border of the scapula.

  → Formation of a hematoma in the axillary region which leads to the compression of neural elements.

  → Vascular injury leading to the formation of a pseudoaneurysm of the axillary artery; this causes a delayed compression of neural structures, and deterioration of limb function.

  → Injury to vasa nervorum causing ischaemia of peripheral nerves resulting in impairment of their function.

Most injuries resulting from shoulder dislocation affect mostly the infraclavicular part of the plexus, in many cases extending up to the retro-pectoralis minor space.

• (This is likely because trauma in abduction causes injury to the lower part of the brachial plexus.)

• Position of the limb during dislocation influences site of nerve injury.

  → Medial cord when elbow and wrist are extended.

  → Medial and posterior cords when the elbow is flexed.

  → All cords when shoulder is in 90º abduction and full extension.

• The posterior cord is the most likely to be injured.

• Injury to the axillary nerve is most common, singly or in combination with other nerves.

• Multiple nerve injuries are more common than singular nerve injuries after shoulder dislocation.

• Short branches of the brachial plexus can also be injured, with the suprascapular nerve most commonly reported.

• Clinically, axillary nerve and suprascapular nerve injuries may present similarly, and can also present together.

  → They may also present as shoulder instability and/or rotator cuff tears.

  → Nerve conduction studies are the only way to differentiate between axillary and suprascapular injuries.

• A rare associated injury may be neurovascular injury to the axillary or subclavian arteries.

• Spontaneous recovery will take > one year and make need surgical intervention.

• Observed nerve injuries are most often neuropraxia or axonotmesis.

  → Complete disruption or avulsion is very rare.

  → Neurotmesis require nerve grafting occurred in 22.7-29% of cases.

• Infraclavicular injuries require surgery significantly less often than supraclavicular injuries.

  → Timing of surgery is controversial, and there is yet no consensus.

• Factors affecting surgical recovery include:

  → Age (less than 40 years).

  → Severity of nerve lesions.

  → Time between trauma and surgery.

  → Graft length.

  → Lateral cord recovers better than posterior or medial cord.

• Elevated risk of neurological injury after shoulder dislocation is associated with variables such as:

  → Higher patient age

  → Male gender (due to a higher preponderance to be involved in high-energy collisions, not due to sex differences).

  → Increased time between dislocation and relocation.

  → Coexisting rotator cuff tear or greater tuberosity fracture.

  → Coexisting haematoma.

• Infraclavicular injuries have a better prognosis for recovery.

• Sensory recovery precedes motor recovery.

Clinical Pilates in practice

• Given that neurological sequelae may present similarly to instability and/or rotator cuff tears, it is important to continue to screen neurological signs and symptoms through injury management and recovery. 

• Consider the mechanism of injury and the position of the upper limb during shoulder dislocation, for clues as to which cords may be compromised, and therefore which peripheral nerves may exhibit damage. 

• Work to decompress the brachial plexus, especially the infraclavicular area: ACJ + SCJ and rib mobility are crucial. 

  → Hug a Tree on the Mat.

  → Side Arm Press on the Cadillac. 

• Posterior shoulder cuff engagement will support the stability of the shoulder and also facilitate anterior decompression: 

  → Hitch-Hiker and Single Arm Press on the Reformer.

  → Triceps Press on the Wunda Chair (care not to over-stretch the subclavian vessels).

• Integrate elbow, forearm, and wrist mobility within safe parameters for neurodynamic mobility.