Overview
Injury to the brachial plexus as a result of birth trauma, often referred to as brachial plexus birth injury (BPBI), encompasses a spectrum of injuries ranging from neuropraxic lesions to more severe avulsions. These injuries predominantly affect infants but can also manifest in adults, particularly in athletes who experience traumatic events such as stingers during contact sports. While the epidemiology and clinical presentation of BPBI in infants are well-documented, the overlap with adult traumatic injuries, especially in high-impact sports, highlights the importance of recognizing and managing these conditions effectively across different age groups. This guideline aims to provide a comprehensive overview of BPBI, focusing on clinical presentation, diagnosis, management, complications, prognosis, and key recommendations based on current evidence.
Epidemiology
Brachial plexus injuries, particularly those occurring as birth trauma, are relatively rare but significant in their impact on affected individuals. In the context of sports, particularly American football, stingers—temporary neuropraxic injuries to the brachial plexus—are a notable concern. A study among NFL athletes revealed that the incidence of stingers was notably higher during regular season games (12.26 per 100,000 player-plays) compared to preseason games (8.87 per 100,000 player-plays) [PMID:38229225]. This suggests that the higher intensity and frequency of contact during regular seasons contribute to increased injury risk. Among specific positions, running backs and linebackers exhibited the highest incidence rates, exceeding 15 per 100,000 player-plays, indicating that biomechanical factors related to these roles may predispose them to greater vulnerability [PMID:38229225]. These findings underscore the need for targeted preventive measures and early intervention strategies in high-risk sports populations.
Clinical Presentation
Patients presenting with brachial plexus birth injuries (BPBI) often exhibit a constellation of symptoms that can vary in severity. In infants, common manifestations include weakness or paralysis in the affected arm, Horner's syndrome, and diminished or absent reflexes in the upper extremity. However, in adult athletes experiencing traumatic injuries like stingers, clinical presentations tend to be more acute and transient, characterized by sudden onset of shoulder and arm pain, numbness, and tingling, often exacerbated by neck movements. A specific subset of BPBI patients may present with anterior shoulder pain alongside restricted mobility, which can sometimes be indicative of additional pathologies such as coracoid impingement. Imaging studies, particularly MRI, play a crucial role in diagnosing these conditions. For instance, MRI findings showing a percentage of the humeral head anterior to the scapular line (PHHA) less than 10% or ultrasound evidence of the humeral head ossific nucleus entirely posterior to the posterior scapular line can support the diagnosis [PMID:40292787]. Clinical symptoms such as pain localized to the coracoid process and reduced shoulder mobility further guide the suspicion towards coracoid impingement, necessitating a multidisciplinary approach for comprehensive evaluation [PMID:40590640].
Diagnosis
Diagnosing brachial plexus injuries (BPBI) requires a thorough clinical assessment complemented by advanced imaging techniques. In the context of BPBI, imaging studies are pivotal for confirming the extent of nerve damage and identifying associated anatomical abnormalities. MRI is particularly valuable, offering detailed visualization of soft tissue structures and helping to quantify parameters like PHHA, which can differentiate between normal anatomy and conditions such as coracoid impingement [PMID:40292787]. Ultrasound also plays a significant role, especially in assessing ossification patterns and identifying structural anomalies like a posteriorly displaced humeral head ossific nucleus [PMID:40292787]. Additionally, identifying dysplastic anatomical features, such as a dysplastic coracoid process, through imaging studies is crucial for diagnosing conditions like coracoid impingement in BPBI patients [PMID:40590640]. Clinical symptoms, including pain, limited mobility, and specific neurological deficits, must be correlated with imaging findings to establish a definitive diagnosis. This integrated approach ensures a comprehensive understanding of the injury, guiding appropriate management strategies.
Management
The management of brachial plexus birth injuries (BPBI) and traumatic injuries like stingers in athletes involves a multifaceted approach tailored to the severity and specific manifestations of the injury. For infants with upper trunk BPBI experiencing persistent anterior shoulder pain, surgical interventions such as coracoid excision have shown promising outcomes. A retrospective study involving five patients demonstrated significant reductions in pain scores (from 6.5-8.5/10 to 0-3/10) and notable improvements in range of motion and patient-reported outcomes following coracoid excision [PMID:40590640]. In the context of traumatic injuries in athletes, surgical interventions for associated conditions like glenohumeral dislocation have also yielded positive results. Thirty-two infants underwent surgical treatment for glenohumeral dislocation before the age of one, with substantial improvements in passive and active external rotation and significant enhancements in global Mallet scores [PMID:40292787]. Among these patients, those who received external rotation tendon transfer (ERTT) exhibited a lower reoperation rate (12.0%) compared to those who underwent release alone (85.7%), highlighting the efficacy of more comprehensive surgical approaches [PMID:40292787]. Conservative management, including activity modification, pharmacological interventions, and physical therapy, remains foundational, especially in the initial stages, but surgical options should be considered for refractory cases or when significant functional deficits persist.
Complications
Brachial plexus injuries, whether congenital or traumatic, are associated with several potential complications that can impact long-term outcomes. In the context of stingers among athletes, concomitant injuries are relatively uncommon, occurring in only 7.09% of cases, suggesting that isolated brachial plexus injuries are more frequent [PMID:38229225]. However, when complications do arise, they can be significant. For instance, recurrent internal rotation contracture, redislocation of the shoulder, persistent external rotation weakness, and weak abduction have necessitated further surgical interventions in some patients [PMID:40292787]. These complications underscore the importance of vigilant follow-up and timely intervention to prevent long-term functional impairments. In infants with BPBI, delayed or inadequate treatment can lead to chronic shoulder instability, muscle atrophy, and joint contractures, emphasizing the need for early and precise diagnosis and management strategies.
Prognosis & Follow-up
The prognosis for brachial plexus injuries varies widely depending on the severity and timing of intervention. In the realm of sports-related stingers, the majority of athletes (76.41%) experience complete recovery without requiring time off from their activities, with those needing time off averaging only 4.79 days of absence [PMID:38229225]. This indicates a generally favorable short-term prognosis for many athletes. For those undergoing surgical interventions, such as coracoid excision, follow-up data reveal substantial improvements in pain reduction and functional outcomes. Patients experienced significant reductions in pain scores and notable enhancements in physical and upper extremity function, with no complications noted during follow-up periods ranging from 7.5 months to 1 year and 7 months [PMID:40590640]. Long-term outcomes, as seen in studies with an average follow-up of 4.6 years, demonstrate sustained improvements in shoulder function without notable declines in internal rotation, suggesting durable benefits from appropriate surgical interventions [PMID:40292787]. Regular follow-up assessments are crucial to monitor recovery progress and address any emerging complications promptly, ensuring optimal long-term outcomes for patients.
Key Recommendations
These recommendations are informed by current evidence and aim to optimize patient care across various stages of BPBI and traumatic brachial plexus injuries.
References
1 Lamplot JD, Petit C, Lee R, Mack CD, Herzog MM, Solomon GS et al.. Epidemiology of Stingers in the National Football League, 2015-2019. Sports health 2024. link 2 Lee EY, Shin AY, Shaughnessy WJ, Pulos N. Preliminary Results of Coracoid Excision for Anterior Shoulder Pain in Brachial Plexus Birth Injury. Journal of pediatric orthopedics 2025. link 3 Al Muhtaseb T, Lamer S, Allgier A, Miller MA, Little KJ, Mehlman CT et al.. Surgical Treatment of Infantile Shoulder Dislocation Following Brachial Plexus Birth Injury. Journal of pediatric orthopedics 2025. link