Transient neurapraxia: tactics and treatment
Brachial plexus injury (Brachial plexus), known in sports medicine as a «stinger» or «burner», requires immediate removal of the victim from activity. The physician must perform a rapid screening of all four extremities and the neck to rule out severe neurological deficit.
The basis of management for such patients is conservative treatment:
- Ensuring rest and performing light stretching of the affected extremity.
- Use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the first few days for effective pain relief.
- Initiation of physical therapy (PT) with specific posture-correction exercises if symptoms persist for more than a few days.
Surgical intervention is practically not used. Even in severe injuries (grade 3 with complete axonotmesis), attempts to surgically repair nerves demonstrate poor clinical outcomes. The prognosis for primary episodes is excellent, and disability occurs extremely rarely.
Diagnosis and prevention of neck injuries
When examining athletes, it is important not to miss occult bony pathology. If pain or neurological abnormalities persist for more than a few minutes, the patient is strongly advised to undergo cervical spine radiography (Cervical spine) to rule out dislocations or fractures.
The main risk factor is contact sports involving forceful tackles. The situation is significantly aggravated by anatomical predisposition: the presence of cervical spinal stenosis in the patient increases the likelihood of injury.
Two main approaches are used to prevent recurrences:
- Biomechanics education: using a more upright posture during tackling reliably protects the neck from pathological hyperextension.
- Use of equipment: application of shock-absorbing pads and specialized cervical collars to absorb the kinetic energy of impact.
Scapular biomechanics and conservative therapy
The scapulothoracic articulation is not a true synovial joint. It is an extensive contact area where the scapula slides over the chest wall. The only bony connection with the trunk here is the clavicle. At rest, the scapula is internally rotated by approximately 30° and slightly tilted forward.
Pathologies of this zone are closely associated with muscle imbalance (17 muscles are involved in stabilization) and are treated predominantly conservatively:
- Snapping scapula syndrome: occurs due to overloads and scapulothoracic bursitis. Chronic inflammation of the synovial bursae leads to fibrosis, causing noticeable friction and crunching.
- Scapulothoracic dyskinesia: abnormal mobility of the scapula that disrupts the mechanics of the entire shoulder joint and leads to pronounced pain syndrome.
During physical examination, the physician should assess posture (presence of kyphosis or scoliosis), as well as the range of passive and active motion. It is important to remember: the presence of crepitus without concomitant pain is not a direct indication for treatment.
Differential diagnosis of scapular winging
Scapular winging is a consequence of stabilizer muscle weakness, which disrupts the traction balance. Depending on the affected structure, three types are distinguished:
- Medial winging. Occurs with dysfunction of the serratus anterior muscle (m. serratus anterior) due to injury to the long thoracic nerve (n. thoracicus longus). The scapula is displaced by the action of the rhomboid muscles and trapezius. Detected by the «wall push-up» test.
- Lateral winging. Associated with weakness of the trapezius muscle (m. trapezius) against the background of accessory nerve injury (n. accessorius), which is often a consequence of neck surgeries. For diagnosis, the scapular «drop» sign during resisted shoulder external rotation is used.
- Pseudowinging. Develops without neuromuscular pathologies. The cause may be a space-occupying lesion (osteochondroma) physically pushing the bone away from the chest wall, or a compensatory habit of the patient to avoid pain.
Briefly: answers to topical questions
Which muscles are involved in scapular stabilization?
Scapulothoracic stabilization involves muscles connecting the scapula to the trunk. The main stabilizers include:
- Serratus anterior muscle (m. serratus anterior) — its weakness causes medial winging of the scapula.
- Trapezius muscle (m. trapezius) — its dysfunction leads to lateral winging.
- Rhomboid muscles (mm. rhomboidei) — participate in scapular retraction and pull it unopposed in case of serratus anterior weakness.
What anatomical structures and spaces form the scapulothoracic articulation?
The scapulothoracic articulation is not a true synovial joint, but rather an extensive contact area between the anterior surface of the scapula and the rib cage. The following structures participate in its function:
- Clavicle (clavicula) — provides the only ligamentous connection between the scapula and the trunk.
- Scapulothoracic bursae (bursae) — ensure the gliding of the scapula along the chest wall.
What are the radiological signs of cervical spinal stenosis?
Radiological signs of cervical spinal stenosis include a reduction in its dimensions and degenerative changes. The main criteria include:
- Absolute stenosis (absolute stenosis) — anteroposterior canal diameter less than 10 mm.
- Relative stenosis (relative stenosis) — diameter from 10 to 13 mm.
- Torg-Pavlov ratio (Torg-Pavlov ratio) — value less than 0.8.
Additionally, signs of spondylosis are detected:
- Osteophytes (osteophytes).
- Disc space narrowing (disc space narrowing).
- Facet joint hypertrophy (facet joint hypertrophy).
- Anterolisthesis (anterolisthesis) — anterior displacement of the vertebra during functional tests.
Which spinal nerves form the brachial plexus?
The brachial plexus is formed by the ventral and dorsal components of five nerve roots from C5 to T1. These components merge into cervical spinal nerves, which exit the spinal canal and unite into three primary trunks:
- Superior trunk (Superior trunk) — formed by roots C5 and C6.
- Middle trunk (Middle trunk) — formed by root C7.
- Inferior trunk (Inferior trunk) — formed by roots C8 and T1.
Structure of the brachial plexus (Roots, Trunks, Divisions, Cords, Branches): Randy Travis Drinks Cold Beer (Roots, Trunks, Divisions, Cords, Branches). Terminal branches forming the «M» shape (musculocutaneous, median, ulnar nerves): MuMU (μ, M in the Greek alphabet).
Class and exam questions
When is an athlete cleared to return to training after a "stinger"?
Return to play is permitted exclusively after complete resolution of all symptoms, restoration of normal muscle strength, and 100% range of motion of the affected arm.
Which diagnostic test reveals medial scapular winging?
The most indicative is the «wall push-up» test. It demonstrates weakness of the serratus anterior muscle and failure of protraction.
Can recurrent "stingers" cause irreversible nerve damage?
A history of previous episodes increases the risk of recurrent injuries, but to date there is no convincing clinical evidence that recurrences lead to irreversible damage.
What else to study on this topic
- Brachial plexus anatomy: formation of cords and branches.
- Biomechanics of the shoulder joint and scapulothoracic articulation.
- Scapulothoracic dissociation: mechanisms of high-energy trauma.
- Impact of cervical spinal stenosis on sports injury risks.
Master the entire topic in the "Traumatology" course
This is a summary. The course covers everything tested in classes and exams.
- Complete guide on "Conservative Treatment of Spinal Diseases" and 812 more pages on the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 35 video lessons on the subject
Other Topics in "Orthopedics"
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.