There are varying statistics about the epidemiology of traumatic brachial plexus injuries in different parts of the world. The report by Narakas is considered as an important reference. It is a larger series with 1068 patients over a span of 18 years elucidating the type of presentation and treatment of brachial plexus injuries.[5
] Narakas had stated the rule of seven seventies, which frequently forms the guidance values; our results were compared and variation in our population were noted.
Terzis from USA studied the outcomes of 204 patients who underwent reconstruction for brachial plexus injuries over the period of 18 years and enumerated few of the epidemiological aspects in her study like the gender ratio, injured side, vehicle associated with brachial plexus injury, speed of the vehicle at which the accident occured and the associated injuries.[9
] Kim from USA studied the outcome of surgery in 1019 brachial plexus lesions but this study included tumours and thoracic outlet syndrome.[10
] Our study group involves only post-traumatic brachial plexus injuries and does not include iatrogenic injuries or tumours of the brachial plexus. This study is also a retrospective study as other studies, but in addition we have the data from 144 patients as to their long-term status. Though we are able to contact only about half of the study population, the contactable number in itself is a good sample size to know as to what happens regarding work status and their adaptability with the other hand in the long term.
Road traffic accidents are the predominant cause of traumatic brachial plexus injuries in most of the studies but the contribution of road traffic accidents towards the brachial plexus injuries varies in different studies. Songcharoen reported that 91% of the brachial plexus injuries in Thailand were due to road traffic accidents and 82% were due to motorcycle accidents.[11
] Dubuisson from Belgium reported that 60% of the traumatic brachial plexus injury were due to road traffic accident and 31% occurred while riding a two wheeler.[12
] Kandenwein from Germany found that 81% traumatic brachial plexus injuries were due to road traffic accidents and 65% of the injuries involved two wheelers.[13
] In our study, we found that 94% of the traumatic brachial plexus injuries were due to road traffic accidents and 90% of these road traffic accidents are associated with two wheelers, which is similar to the Thailand report but different from the western literature. This clearly indicates the kind of vehicles used and the economic status of the country. Other cause for brachial plexus injuries in the study done by Narakas and Dubuisson, which was not seen in our study, was sports-related injury.
We had only 2 open injuries out of the 304 brachial plexus injuries in our study, whereas the study done by Dubuisson had 23 open injuries out of 100 patients.[12
] Kim from USA reported 19% open injuries in the form of laceration and gunshot injuries to brachial plexus.[10
] In our study, 54% of the patients were part of polytrauma and 46% were isolated brachial plexus injuries. This study gives an idea of the pattern of brachial plexus injury which a referral centre will see. Terzis showed that 57% had some fracture and 20% had clavicle fracture in the involved extremity.[9
There were 14 vascular injuries out of 304 patients which is 4.6% in our study, but Terzis reported 28% associated vascular injury. Van der Werken found that 20% had associated vascular trauma.[14
] In centres which receive more high-velocity trauma, vascular injury appears to be more common. Clavicle was the most frequently associated fracture reported by Kandenwein, which was 20.9%, whereas in our study we found clavicle fracture in 11% of the patients.[13
] There were two individuals who had a clavicle fracture and an associated vascular injury. Lesser number of associated injuries suggests that the injuries sustained in our population could be due to low velocity when compared to the west. Femur was the most common bone to be fractured, followed by humerus, clavicle and tibia in our series.
Eighty-nine per cent had at least one of the roots avulsed. Of the avulsed roots, 59% involved C7, C8 and T1. Ninety-six per cent of the patients who underwent brachial plexus exploration had supraclavicular lesion. Brophy had found that 70-75% of the lesions were supraclavicular.[15
] A study by Narakas in 1977 found that 86.6% had brachial plexus injury in the supraclavicular level.
The dominant arm was found to be the most commonly injured, which is the right side. This is similar to many other studies. This reinforces that the side of the road used for driving does not determine the side of the arm affected.[16
When considering the speed of the vehicle during which the accident occurred, we found that the study done by Terzis provides some information, Terzis reported that the speed at which the accidents occurred ranged from 25 to 120 mph and the average speed was 54.5 mph.[9
] In our study, speed ranged from 10 to 120 km/h and the average speed at which the accident occurred was 47 km/h (29 mph). Four of them were stationary and four of them did not remember the speed at which they were travelling. Two wheeler accidents were the most frequent mode of injury. The principal factors determining the extent of injury are the energy imparted by the blow and to a lesser degree, the direction and the relationship of the arm to the neck during the injury.[17
] The speed at which the brachial plexus injuries occur due to road traffic accidents in our study is lower than the other studies.
The average time interval from the date of injury to exploration of the brachial plexus was 127 days and 124 (40.78%) patients presented to us within this duration. This reflects the awareness among the patients about centres treating brachial plexus injuries. This is a good trend in a developing country. Patient, public and peer education can even probably reduce this time interval.
The presence of pain has shown a wide range of incidence in various studies. In our study, 24% of the patients had pain at the time of presentation. Eleven per cent had complete relief of pain after surgery and 6.9% continued to have intractable pain. Eleven per cent of the patients consumed medications for pain and one of them even consuming medications up to 3 years. In one of the study by Choi, he reported that 75% had severe pain and 38% of them continued to take medications for pain.[18
There are two reports on quality of life in brachial plexus injury patients, one of them is by Choi and the other one is by Kitajima.[18
] Choi had studied overall satisfaction, employment status and the impact of brachial plexus injuries on other life domains. This study had 32 subjects and had adopted the interviewer form from the US General Society Survey. But this cannot be extrapolated to our society. Kitajima evaluated the correlation between the SF-36 scores and the upper extremity function, and they concluded that SF-36 is not sensitive enough to evaluate regional conditions. We consider joining back to work as an important indicator of successful adaptation after injury. Hence, we assessed return to work in 144 patients. Eighty three (57%) of the 144 were doing some form of gainful employment at an average period of 8.6 months from the date of surgery. Thirty four of them returned back to the same work and others had a working pattern with lower demanding jobs. 13 patients out of the 83 patients had global brachial plexus injury. This was possible by reallocating the type of work for the employee, like doing a desk job or a job requiring computing skills. These patients who had joined work were more satisfied and integrated with the society.Discussing the social impact of this devastating injury, it is important to note that one committed suicide, the exact reason was not known. He was a 32-year-old male labourer with global brachial plexus injury. Global brachial plexus palsy patients are dependent on their family for a very long time. We encourage the patients and their family members to help them join back work at the earliest. Less rewarding outcomes of the treatment have been noticed by us and also by other surgeons if they are not encouraged to join some form of gainful employment.[9
The other finding of this study is the ability of the injured to get accustomed to write with their non-dominant hand and duration after which they started working. Thirty seven (25.6%) of the 144 patients were able to recollect about the duration which they took to write in the non-dominant hand. Most of them started to write their name and to affix their signature by 3 months, as this was a necessity to do their bank transactions or other routine activities. As the implication of this disability is more in the global brachial plexus palsy rather than the upper brachial plexus palsy, we found that 21 of the 37 patients who had global brachial plexus palsy were able to write with their non-dominant hand by an average of 6.8 months; the earliest was by 1 month and the longest duration was by 18 months from the time of injury.