What is the diagnosis?

The patient is likely suffering from an acute burner/stinger, also known as “dead arm syndrome”. This is a peripheral nerve injury and a type of brachial plexus injury, typically to the upper trunk.

• Pearl: It is important to perform a trauma assessment to evaluate for emergent causes such as head injury, spinal cord injury, or direct bony trauma of the neck or shoulder.

What is the mechanism of injury?

There are three possible mechanisms of injury: traction injury from stretch, percussive injury from a direct blow, or neck hyperextension with ipsilateral flexion causing direct nerve compression [1-6]. See Image 2 for a brief and traumatizing reminder of the brachial plexus.

What physical exam findings are present?

Transient findings of weakness or sensory abnormalities that can last for up to two days, but often resolve within minutes to hours. Serial examinations may be required. In a true stinger, cervical spine range of motion should be full and intact without midline tenderness. Weakness in the C5 and C6 distribution (deltoid, biceps) can also be present [7]. 

• Pearl: Spurling’s test can be positive. See this video for how to perform it.

What imaging modalities can be used?

Utilize clinical decision rules such as the Canadian C-spine or NEXUS criteria to help determine next steps. If the patient still has objective neurologic deficits, computed tomography (CT) should be considered to rule out bony cervical pathology. There is usually no role for emergent MRI for diagnosis [8].

• Pearl: For a chronic stinger, EMG can be used to assess injury to the roots, cords, trunks, and peripheral nerves if symptoms persist longer than 3 months [7].

What is the management in the ED?

A thorough history and physical examination to evaluate for other serious injuries is pertinent. Rapid resolution of a stinger and lack of prior history of stingers indicates a good prognosis. Reassurance is important as there is no current evidence that there is risk for permanent nerve injury.

• Pearl: Athletes should follow up with sports medicine or physiatry for medical clearance in return to play. Determination of clearance and further evaluation is nuanced especially if the stinger has occurred more than once.

When do you consult Orthopedics?

Consultation is not usually warranted unless there are associated bony injuries. In cases of persistent weakness, serial examinations and advanced imaging may warrant consultation or admission - however, this is institutionally dependent.