**1. Introduction**

Although they have a low incidence [1–3], brachial plexus injuries continue to be a cause of serious disability [4]. Their victims are mostly young people in the middle of their lives or newborns, always with worrisome long-term consequences [2–4]. Unfortunately brachial plexus lesions can also be the result of iatrogenic injuries [5]. The quality of life of those affected is devastated, with high personal [4, 6], familial [7], and societal costs [8, 9].

Nowadays, road accidents in young people continue to be the most common cause, particularly when the victim is thrown in the air and lands on the shoulder [2, 5, 10]. This is particularly common in developing Third World countries, where people have to recourse to the motorcycle for their daily transportation [1, 11–14], as a car is an option outside their reach. Other causes are wars [15–17] and assaults [18, 19]. The incidence is higher in males than in females [1, 2, 13, 20], probably related to the highest aggressiveness and violent behavior in the former [21]. In newborns brachial plexus injuries are usually due to problems during vaginal delivery [3, 22], particularly in case of a macrosomic fetus [23, 24], common in diabetic mothers [25]. In the developed countries, the fear of unpleasant medicolegal consequences in case of an obstetric brachial plexus injury has induced a significant increase in the proportion of cesarean section deliveries [26, 27]. The incidence of iatrogenic brachial plexus lesions unfortunately continues to be stable overtime with no signs of reduction [5, 28–30]. These iatrogenic lesions are induced while performing lymph node biopsy [5, 31, 32], vessel catheterization [33, 34], on applying radiotherapy in the treatment of cancer [35, 36] repairing upper limb bone fractures [37, 38], in programmed orthopedic procedures [39, 40], due to inadequate patient positioning [41, 42] or when restraining aggressive patients [43]. Preventing these iatrogenic injuries is particularly important, not only because they might lead to ugly medicolegal consequences [28] but because of our motto "primum non nocere"

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

(first do no harm) [44]. Any measure or technical improvement aiming to decrease the chance of these unwanted iatrogenic injuries will always be most welcomed. Knowledge, awareness, and training of all hospital personnel must be a priority in our daily basis [45].

useful in nerve injuries affecting the distal parts of the upper limb, as other techniques like the nerve repair, direct or with nerve grafts, yield poor results [47, 70, 77]. The growing axons coming through the nerve repair take so long to reach the hand intrinsic muscles that when they do it find them atrophied and fibrotic [78–81]. Meanwhile, the nerve transfers provide new axons close to the injured muscles with an early and efficient repair [72, 76]. At times an end-to-side nerve transfer can be added to keep the muscles viable, while the growing axons from the direct primary nerve repair to reach their final destination in the motor end plates [82]. Nerve transfers solve the problem of a long distance between the lesion site and the motor end plates to be reinnervated [6, 49, 72, 76]. They can also be used in case of delayed patient referral [83] or dense scar at the primary injury site [84]. Sensory nerve transfer is another very promising area [85, 86], particularly in tetraplegic patients [87, 88], and can also

Introductory Chapter: Brachial Plexus Injuries - Past, Present, and Future

http://dx.doi.org/10.5772/intechopen.81675

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Currently, there is an intense research on pharmacological agents that accelerate the axonal regeneration, shortening the time needed to achieve the reinnervation [90, 91]. Other areas of research are the use of stem cells and growth factors as well as the search for artificial conduits that could substitute the autologous nerve grafts [90, 92]. The most serious injuries, the nerve root avulsions, are still awaiting an effective solution. Reimplantation has been attempted but

Treatment of a complete brachial plexus avulsion with its resultant flail arm poses still a

movements are regained with limited use in the daily life [93]. Some have recommended

Tetraplegic [88] and stroke [95] patient treatments are an area of expansion, aiming to recover some functions in the upper limbs that can improve their quality of life [88, 96]. The rationale behind is to use nerve transfers to recover specific functions (like finger movement) in areas

Some technical refinements have been described attempting to reduce the chance of iatrogenic injury in cases of anesthetic brachial plexus block [98, 99]. The use of ultrasonography can be of invaluable help [100]. Some recommendations on patient positioning have also been forwarded [44]. The long-term commitment of every hospital employee is essential to minimize

A final word should be said on how to start, develop, and consolidate a new peripheral nerve unit. This can be a major endeavor that demands continued devotion and long-term commitment. Once you start in this field, first you have to be known and accepted in your own hospital and then in your community. Time and persistence are needed to get the confidence of the referring doctors

nerve root transfer, only some primitive

help to control the neuropathic pain [89].

**3. Future treatment possibilities**

serious challenge [49]. Even with contralateral C7

upper limb amputation in these unfortunate cases [94].

of irreversible spinal cord or motor strip damage [76, 97].

the results are dismal [50].

these unwanted mishaps.

**4. The future in your own hospital**
