Procedures · Peripheral Nerve & Brachial Plexus Surgery

Brachial Plexus Injury

Medically reviewed by Dr. Khalid Almutairi, Consultant Plastic Surgeon — updated 2026-08-13

The brachial plexus is the network of nerves that leaves the spinal cord in the neck and carries movement and sensation to the entire upper limb — from the shoulder to the fingertips. Severe injury, most often from motorcycle and road accidents that wrench the head away from the shoulder, can paralyse the arm completely or partially.

This is among the most complex of nerve injuries and among the most life-changing — but it is not a closed road. A range of reconstructive tools now exists, chosen and sequenced according to each case.

Care is led by Dr. Khalid Almutairi, a consultant plastic and reconstructive surgeon, fellowship trained in hand surgery and microsurgery in Canada and the USA.

What does the injury cause?

The effect depends on which roots and nerves are involved. Shoulder and elbow movement may weaken while the hand survives — the common upper pattern; the hand may be mainly affected; or the whole arm may be paralysed in complete injuries. Sensory loss accompanies this to varying degrees, and severe nerve pain may appear, particularly when roots have been avulsed from the spinal cord.

Assessment: mapping the injury

The first goal is to establish which roots and nerves are injured, whether the damage lies before the exit from the spinal cord (root avulsion) or beyond it, and whether it is complete or partial — because these details decide what can be repaired and what must be bypassed with nerve transfers. Assessment rests on:

• Careful, repeated clinical examination of every muscle group and sensory territory, watching for any signs of spontaneous recovery.
• Electrodiagnostic studies (nerve conduction studies and EMG) where needed, to localise and grade the injury and to detect early reinnervation.
• MRI where indicated, to assess the roots and spinal cord.
• The time factor: the team balances allowing spontaneous recovery a fair chance against not missing the window for reinnervating the muscles.

The principle of priorities: restore what matters most, first

In severe injuries, every lost function cannot usually be restored. Reconstruction is therefore built on an explicit ranking of priorities agreed with the patient. At the top, most often: shoulder stability and useful positioning; then elbow flexion — the movement that brings the hand to the body and face; then selected hand functions according to the case. Priorities differ between patients with their work and their lives.

The reconstructive tools

Tools are chosen and sequenced according to the injury map and its timing:

• Neurolysis: freeing nerves that are intact but trapped in scar.
• Direct repair or grafting: suturing nerves, or bridging gaps with nerve grafts, where a root is repairable.
• Nerve transfers: redirecting well-functioning nerves or branches — whose contribution can be safely spared — to vital targets. A core tool where roots are avulsed, or to shorten the regeneration distance to the muscle.
• Tendon transfers: once paralysis is established and stable, replacing specific movements using working muscles.
• Free functional muscle transfer (FFMT): in late or complete paralysis, transferring an entire muscle with its vessels and nerve by microsurgery to create new movement — it has its own dedicated page.
• Secondary shoulder or joint procedures where needed to improve position and function.

Birth-related injury differs from adult injury

The plexus can be injured during birth, and many infants recover spontaneously over the first months with regular review and physiotherapy that keeps the joints supple. Cases whose movement does not improve on the expected schedule are assessed for early nerve reconstruction, and some later need surgery to balance the shoulder. A child's pathway of assessment and decision-making is distinct from an adult's, and is managed individually with the family.

A long journey: recovery and rehabilitation

Plexus reconstruction is a project measured in months to years. The nerve regenerates slowly toward its targets; new movement appears gradually and its strength is then built through training. Physiotherapy is a constant companion — first protecting the joints, then retraining the brain to use new pathways after nerve or tendon transfers. The plan may unfold across sequential surgical stages, and this is explained from the outset.

Realistic expectations and limitations

No specific extent of recovery can be guaranteed; the outcome is shaped by the injury pattern and level, the timing of treatment, the patient's age, and adherence to rehabilitation. The realistic goal is to restore useful functions that make a genuine difference to independence — not to return the arm exactly to what it was. Risks include incomplete recovery, weakness at donor-nerve sites, and sometimes persistent nerve pain, in addition to general surgical risks — all discussed frankly before each stage.

Can the injury improve on its own?

Some patterns do improve spontaneously — particularly incomplete stretch injuries — which is why patients are followed with regular examination. But unlimited waiting can lose the reinnervation window; balancing the two is the heart of the timing decision, and it is managed with specialist assessment.

When should specialist assessment happen?

Any clear paralysis or weakness of the arm after an accident deserves early specialist assessment — even when the first plan is observation. Early assessment does not mean immediate surgery; it ensures the muscles' time is not wasted.

Is treatment still useful years after the injury?

Once the reinnervation window has passed, the functional-reconstruction options — tendon transfer, free functional muscle transfer, and secondary procedures — remain open for consideration in selected cases, determined by examination.

Medical-information notice

This is general information and does not replace specialist consultation and examination. Every plexus injury is assessed individually, and the appropriate treatment pathway and facility are determined by the case and facility requirements.