Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Burners (Stingers)

Basics
Description
  • Burners (also termed stingers) are traction injuries that result in a neurapraxia of the brachial plexus.
  • Patients typically report pain that radiates into the shoulder and down the arm to the hand, which is usually described as a dead arm.
  • These injuries are common in tackling sports and usually occur in teenagers and young adults.
  • One of the most common injuries in football.
  • Usually associated weakness of shoulder abduction (deltoid), elbow flexion (biceps), and external humeral rotation (spinati).
  • The brachial plexus injury typically involves only the upper trunk.
Epidemiology
Males are affected more often than are females.
 
Risk Factors
  • High-impact sports
  • Motorcycle crashes
  • Cervical stenosis may predispose an athlete to a burner syndrome because of concomitant foraminal narrowing with nerve root compression.
Etiology
  • Typically secondary to ipsilateral shoulder depression with lateral neck deviation to the contralateral side.
  • A direct blow to the supraclavicular area may occur in football and other contact sports, as well as in motorcycle accidents.
Associated Conditions
  • Horner syndrome
  • Suprascapular nerve compression.
Diagnosis
Signs and Symptoms
  • The distribution of symptoms depends on the level of the brachial plexus injury.
  • Transient numbness or tingling may be present.
  • Weakness of shoulder abduction (deltoid), elbow flexion (biceps), and external humeral rotation (spinati) may occur.
Physical Exam
  • Sideline evaluation should include:
    • Palpation of the cervical spine for tenderness and cervical ROM testing: Cervical tenderness or painful or limited ROM are red flags for a more serious problem.
    • A complete but brief neurologic examination of all four extremities: Sensation and movement may be checked by having the patient flex and extend each joint; test sensation on anterior and posterior surfaces of each limb segment.
    • Manual muscle testing in the affected upper extremity: Arm weakness with decreased sensation may be present, but athletes usually have a normal examination by the time they reach the sideline.
    • Testing for tenderness in the brachial plexus: Tinel sign in the supraclavicular fossa indicates damage to at least 1 nerve root.
Tests
Lab
Electromyographic and nerve conduction velocity studies should be obtained if no recovery of neurologic function occurs in 2-3 weeks (rare).
 
Imaging
  • Radiography:
    • Plain radiographs of the cervical spine, including active flexion and extension views to look for cervical instability and oblique views to visualize the cervical nerve root foramen.
    • Scapular AP and lateral views plus axillary views of the shoulder
  • MRI of the cervical spine for patients with recurrent stingers or persistent neurologic deficit
Differential Diagnosis
  • Cervical spine injury or stenosis
  • Thoracic outlet syndrome
  • Long thoracic nerve palsy
  • Suprascapular nerve compression
Treatment
General Measures
  • Observation and serial evaluations should be performed.
  • Most patients recover within minutes.
  • Return to play is allowed when full strength has returned, all neurologic signs and symptoms have resolved, and cervical ROM is pain free.
  • Patients with recurrent or prolonged (hours to weeks) burner syndrome mandate additional evaluation, including:
    • AP, lateral, oblique, and odontoid views of the cervical spine for assessment of cervical stenosis.
    • If those radiographs are negative, then flexion-extension views to identify ligamentous instability
  • The affected extremity may be placed in a sling for comfort, as needed.
  • The patient should be restricted from sports until the symptoms have resolved and any needed workup is complete.
  • If stingers are recurrent, a change in sport should be considered.
Special Therapy
Physical Therapy
An aggressive neck and shoulder strengthening program should be initiated.
 
Medication (Drugs)
Analgesics may be taken, if needed.
 
Surgery
In general, surgery is not indicated.
 
Follow-up
Prognosis
  • The prognosis is generally poor for patients with supraclavicular injuries and patients with complete neurologic deficits.
  • The prognosis is more favorable for patients with infraclavicular injuries or incomplete neurologic deficits.
Complications
  • Incomplete recovery
  • Muscle weakness or wasting
  • Pain
Miscellaneous
Codes
ICD9-CM
767.6 Injury to brachial plexus
 
Patient Teaching
  • Proper tackling technique should be taught.
  • The motion and position that produce brachial plexus stretch should be explained.
  • Patients should avoid impact on the top of the shoulder or the side of the neck.
Prevention
  • Physical therapy with emphasis on a neck-strengthening program
  • High-profile shoulder pads or a cowboy collar to limit the extent of lateral flexion and extension
  • Education about proper blocking and tackling techniques
FAQ
Q: In the stinger syndrome, weakness most commonly occurs during strength testing of which muscles?
A: In most cases, this injury involves the upper trunk (C5, C6) of the brachial plexus. Thus, weakness may include the deltoid (C5), biceps (C5, C6), supraspinatus (C5, C6), and infraspinatus muscles (C5, C6).
 
Q: What criteria should be used to decide if an athlete can return to play?
A: Most athletes have full recovery within minutes. If full strength has returned and all neurologic signs and symptoms have resolved, return to play is allowed. More prolonged symptoms and/or 3 or more previous episodes of the stinger/burner syndrome should prohibit return to play until additional evaluation is performed.
 
Q: What condition may predispose an athlete to develop the burner/stinger syndrome?
A: Cervical stenosis may predispose an athlete to experiencing a burner syndrome because of concomitant foraminal narrowing with nerve root compression.

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