Brachial plexus injury after clavicle fracture operation: a case report and literature review

Abstract Background Open reduction and internal fixation (ORIF) is the preferred choice for treating clavicle fractures. The brachial plexus injury caused by ORIF of a clavicle fracture is very rare. If it is not treated in time, the function of the brachial plexus will be challenging to recover, which will eventually lead to upper limb dysfunction and seriously affect the patient’s quality of life. Our team recently used ORIF to treat a patient with a clavicle fracture, who developed brachial plexus injury symptoms after surgery. Case presentation A 34-year-old female patient was admitted to the hospital for 13 h due to the right shoulder movement restriction after a fall. Due to the significant displacement of the fracture, we used ORIF to treat the fracture. The surgery went well. When the anaesthesia effect subsided 12 h after the operation, the patient developed right brachial plexus injury symptoms, decreased right upper limb muscle strength, dysfunction, and hypoesthesia. Symptomatic treatments, such as nourishing nerve and electrical stimulation, were given immediately. Sixty days after the operation, the patient’s brachial plexus injury symptoms disappeared, and the function of the right upper limb returned to the preoperative state. Conclusions Patients with clavicle fractures usually need to undergo a careful physical examination before surgery to determine whether symptoms of brachial plexus injury have occurred. Anaesthesia puncture requires ultrasound guidance to avoid direct damage to the brachial plexus. When the fracture end is sharp, reset should be careful to prevent nerve stump stabbed. When using an electric drill to drill holes, a depth limiter should be installed in advance to prevent the drill from damaging the subclavian nerve and blood vessels. When measuring the screw depth, the measuring instrument should be close to the bone surface and sink slowly to avoid intense hooks and damage to the brachial plexus. Try to avoid unipolar electrosurgical units to prevent heat conduction from damaging nerves, and bipolar electrocoagulation should be used instead. If symptoms of brachial plexus injury occur after surgery, initial symptomatic treatment is drugs and functional exercise, and if necessary, perform surgical exploration.

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O09 Recurring brachial plexopathy- the zebra among the horses

Rheumatology Advances in Practice ◽

10.1093/rap/rkab067.008 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

Author(s):

Brooke Mara

Keyword(s):

Case Report ◽

Brachial Plexus ◽

Upper Limb ◽

Brachial Plexus Injury ◽

Mechanism Of Injury ◽

Limb Pain ◽

History Of ◽

Upper Limb Pain ◽

The Right

Abstract Case report - Introduction A case study of a teenage boy presenting with severe upper limb pain and recurring loss of upper limb function with no clear mechanism of injury. His progress in therapy was initially as expected; however, symptoms would recur despite consistency and compliance with treatment from the patient. This led to a referral for further investigations where a diagnosis of a rare inflammatory neurological condition was made. This case study is relevant for paediatric physiotherapists working in non-inflammatory, musculoskeletal and pain services as it highlights a lesser-known pathology that presents in a similar way to a more common condition. Case report - Case description M is a 13-year-old boy that presented with a 5-week history of stabbing pains followed by loss of motor function and sensation in his right arm after swinging a remote. A diagnosis of brachial nerve plexopathy had been suggested. M had been diagnosed with Hypermobile Ehlers-Danlos Syndrome (hEDS) but was otherwise fit and well with no significant birth, developmental or family history. He experienced similar episodes of loss of motor function throughout the entire right upper limb following an episode of acute pain aged 4 and aged 12. The episodes were presumed to be a brachial plexus injury following a shoulder subluxation; however, there was no real mechanism of injury to suggest this and symptoms self-resolved after several months in both instances. Age 8 he lost function and sensation in the left arm after a minor pulled elbow, he underwent elbow surgery at another centre to help restore the function of the left arm; however, function didn’t return for approximately 1 year. On examination he had diminished reflexes throughout the right upper limb and reduced sensation along a C3-8 & T1 distribution. He had a correctable thoracic spine kyphosis with significant medial boarder scapula winging on the right. His right shoulder sat lower than the left and he had muscle atrophy at right supraspinatus, infraspinatus, and serratus anterior and deltoid with tight pectoral muscles. He was compensating using upper trapezius to achieve 90—100 degrees of shoulder flexion and abduction with 2/5 muscle power. His elbow muscle strength was reduced to 4/5 in all movements on the right. He could only actively extend his right wrist to 30 degrees and only had flickers of active radial deviation. He lacked active finger extension in digits 2-5 and had 0/5 muscle activity at the right thumb. Case report - Discussion M underwent exercise therapy with a focus on regaining scapula control in lying and isometric rotator cuff strengthening as he had such significant wasting and was unable to control the upper limb in sitting. We also worked on improving his thoracic spine posture and on active assisted finger and wrist exercises to prevent contractures. I initially provided a sling to be worn at school and in busy environments to prevent any subluxations in view of his significant rotator cuff weakness and history of hEDS. The sling also served as a thoracic posture reminder for M. After just 2—3 weeks of input and initially making gains in strength and function, M had an episode of severe pain in the right shoulder followed by worsening motor and sensory symptoms. The recurrent nature of episodes and the weak mechanism of injury, led me to discuss M with a consultant. The consultant referred M to genetics where it was discovered he had idiopathic neuralgic amyotrophy (INA; also known as Parsonage—Turner Syndrome), a rare inflammatory neurological disorder. M had the classic signs and symptoms of INA but as he had presented to various different clinicians and centres with each episode a correlation wasn’t made until this latest presentation to pain clinic Case report - Key learning points The insubstantial mechanism of injury for his current presentation (motor loss from swinging a remote) led me to probe further into past episodes of his upper limb pain. This information spurred me to research alternative causes of his symptoms and discuss the case with a consultant who made an onward referral. As physiotherapists we are highly likely to receive referrals for patients like M, with little more information than ‘shoulder pain’ or ‘brachial plexus injury’ given, which is why our subjective is such an important part of the overall assessment. M’s case highlights how important collating an extensive medical history is to proper investigation and eventual diagnosis. M had a long history of upper limb events for which he had seen a variety of clinicians at various centres. Each event had been treated as an individual episode rather than one larger recurring pattern. Drawing that history together gave a more holistic picture which triggered the referral that identified a diagnosis 8 years after his first presentation to healthcare. M’s case also highlighted the importance of a good patient—therapist relationship. Motivating a patient with this type of condition is challenging; their progress is not linear and they often have to take steps backwards before they can progress again. This is exceptionally difficult for children and their parents, as it is a frustrating and repetitive cycle. They need to trust that you are giving them the correct therapy and as a therapist you need to trust that the patient is compliant with recommendations and exercise. Finally, the shoulder rehabilitation for M was, clinically speaking, the same as any other brachial plexus type injury. The main key difference was the need to intermittently take the exercises down a level in the incidence of a new episode of pain and motor loss.

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The importance of early and long-lasting medical rehabilitation in patients with brachial plexus injury

Balneo and PRM Research Journal ◽

10.12680/balneo.2021.429 ◽

2021 ◽

Vol 12 (Vol.12, no.1) ◽

pp. 107-110

Author(s):

Roxana SCHEAU ◽

Gabriela IELCIU ◽

Madalina Gabriela ILIESCU

Keyword(s):

Brachial Plexus ◽

Upper Limb ◽

Brachial Plexus Injury ◽

Clavicle Fracture ◽

Rehabilitation Program ◽

Medical Rehabilitation ◽

Motor Deficit ◽

Motor Rehabilitation ◽

Large Motor ◽

Degrees Of Severity

Introduction. Brachial plexus lesions vary in severity, depending on the etiopathogenic mechanism and the level of force to which the plexus is exposed. In the same patient, several nerves of the plexus can be damaged in varying degrees of severity. Brachial plexus injuries lead to upper limb paralysis and disability. Material and Methods. We present the case of a 68-year-old woman diagnosed a year ago with multiple myeloma, clavicular plasmacytoma and secondary spontaneous clavicle fracture. At the same time she presented several dislocations of the shoulder and was diagnosed with brachial plexus palsy after the last dislocation. The patient was hospitalized in our department with a large motor deficit in the upper limb. A comprehensive motor rehabilitation program has been established three weeksafter installing the palsy. Results and discussion. The evolution of the patient was favorable. It was noticed the reduction of the symptoms and slight improvement in motor deficit of the affected upper limb. Thepatient rehabilitation should continue for several months because the nerve regenerates slowly. Conclusion. In patients with brachial plexus injury, motor rehabilitation should be instituted as early as possible and continued for a longer periodoftime until nerve regeneration occurs.It results that early and continuous medical rehabilitation is essential in patients with brachial plexus injury. Keywords: Brachial plexus injury, shoulder dislocation, rehabilitation,

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A low energy paediatric clavicle fracture associated with acute brachial plexus injury and subclavian artery compression

Annals of The Royal College of Surgeons of England ◽

10.1308/003588413x13511609955256 ◽

2013 ◽

Vol 95 (2) ◽

pp. e6-e9 ◽

Cited By ~ 3

Author(s):

I Gill ◽

J Quayle ◽

M Fox

Keyword(s):

Brachial Plexus ◽

Subclavian Artery ◽

Brachial Plexus Injury ◽

Clavicle Fracture ◽

High Energy ◽

Low Energy ◽

Unique Case ◽

Vascular Disruption ◽

Clavicle Fractures ◽

Neurological Injuries

Paediatric clavicle fractures are common injuries presenting to orthopaedic surgeons. The majority of these represent midshaft low energy fractures, which in the vast majority of cases are treated non-operatively and recover rapidly. The main indications to consider operative intervention include high energy of injury, >2cm shortening, open fractures and associated vascular or neurological injuries. Brachial plexus (BP) injuries are uncommon with variable outcomes. They often result from high energy motorcycle related accidents with potentially fatal associated injuries such as vascular disruption. Their management is complex, requiring expertise, and they are therefore usually managed in supraregional centres. We present a unique case of a low energy midshaft clavicle fracture in a paediatric patient in whom there was an acute BP injury and subclavian artery compression that has not been described previously.

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Brachial Plexus Injury Significantly Increases Risk of Axillosubclavian Vessel Injury in Blunt Trauma Patients With Clavicle Fractures

The American Surgeon ◽

10.1177/0003134820952832 ◽

2020 ◽

pp. 000313482095283

Author(s):

Erika Tay ◽

Areg Grigorian ◽

Sebastian D. Schubl ◽

Michael Lekawa ◽

Christian de Virgilio ◽

...

Keyword(s):

Risk Factors ◽

Brachial Plexus ◽

Blunt Trauma ◽

Brachial Plexus Injury ◽

Clavicle Fracture ◽

Trauma Patients ◽

Subset Analysis ◽

Vessel Injury ◽

Clavicle Fractures ◽

National Analysis

Background A national analysis of clavicle fractures is lacking and the risk of concomitant axillosubclavian vessel injury (ASVI) in patients with clavicle fractures is unknown. A minority of patients may have a combined brachial plexus injury (BPI). We sought to describe risk factors for concomitant ASVI in patients with a clavicle fracture; hypothesizing patients with combined clavicle fracture and BPI has a higher risk of ASVI. Methods The Trauma Quality Improvement Program (2010-2016) was queried for blunt trauma patients with a clavicle fracture. A multivariable logistic regression model was used to determine risk factors for ASVI. A subset analysis on patients with isolated clavicle fractures was additionally performed. Results From 59 198 patients with clavicle fractures, 341 (.6%) had concomitant ASVI. Compared to patients without ASVI, patients with ASVI had a higher median injury severity score (24 vs. 17, P < .001) and rates of pulmonary contusions (43.4% vs. 37.7%, P = .029) and BPI (18.2% vs. .4%, P < .001). After controlling for associated chest wall injuries and humerus fracture, the BPI odds ratio (OR 49.17, 35.59-67.92, P < .001) was independently associated with risk for ASVI. In a subset analysis of isolated clavicle fractures, BPI remained associated with risk of ASVI (OR 60.01, confidence intervals 25.29-142.39, P < .001). Conclusion The rate of concomitant ASVI in patients with a clavicle fracture is <1%. Patients presenting with a clavicle fracture had a high rate of injuries including pulmonary contusion. Patients with findings suggestive of underlying BPI had a nearly 50 times increased associated risk of ASVI. Thus, a detailed physical exam in this setting including brachial-brachial index appears warranted.

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A rare variation in the formation of the lower trunk of the brachial plexus its embryological basis and clinical importance - a case report

Journal of College of Medical Sciences-Nepal ◽

10.3126/jcmsn.v6i4.6727 ◽

2012 ◽

Vol 6 (4) ◽

pp. 49-52

Author(s):

N Satyanarayana ◽

R Guha ◽

P Sunitha ◽

GN Reddy ◽

G Praveen ◽

...

Keyword(s):

Case Report ◽

Brachial Plexus ◽

Upper Limb ◽

Clinical Importance ◽

Medical Sciences ◽

Nerve Roots ◽

Rare Variation ◽

Lower Trunk ◽

Male Cadaver ◽

The Right

Brachial plexus is the plexus of nerves, that supplies the upper limb.Variations in the branches of brachial plexus are common but variations in the roots and trunks are very rare. Here, we report one of the such rare variations in the formations of the lower trunk of the brachial plexus in the right upper limb of a male cadaver. In the present case the lower trunk was formed by the union of ventral rami of C7,C8 and T1 nerve roots. The middle trunk was absent. Upper trunk formation was normal. Journal of College of Medical Sciences-Nepal,2011,Vol-6,No-4, 49-52 DOI: http://dx.doi.org/10.3126/jcmsn.v6i4.6727

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Bilateral Anatomical Variation in the Formation of Trunks of the Brachial Plexus - A Case Report

Journal of Morphological Sciences ◽

10.1055/s-0038-1660485 ◽

2018 ◽

Vol 35 (01) ◽

pp. 9-13

Author(s):

E. Lasch ◽

M. Nazer ◽

L. Bartholdy

Keyword(s):

Case Report ◽

Brachial Plexus ◽

Upper Limb ◽

Scientific Literature ◽

Case Reports ◽

Anatomical Variation ◽

Male Cadaver ◽

Motor Nerves ◽

The Right

AbstractThis study presents a bilateral variation in the formation of trunks of brachial plexus in a male cadaver. The right brachial plexus was composed of six roots (C4-T1) and the left brachial plexus of five roots (C5-T1). Both formed four trunks thus changing the contributions of the anterior divisions of the cervical nerves involved in the formation of the cords and the five main somatic motor nerves for the upper limb. There are very few case reports in the scientific literature on this topic; thus making the present study very relevant.

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Accidental contact burns of the upper limb in children with obstetric brachial plexus injury

Burns ◽

10.1016/s0305-4179(99)00043-1 ◽

1999 ◽

Vol 25 (7) ◽

pp. 669-672 ◽

Cited By ~ 12

Author(s):

M.M. Al-Qattan

Keyword(s):

Brachial Plexus ◽

Upper Limb ◽

Brachial Plexus Injury ◽

Obstetric Brachial Plexus ◽

Obstetric Brachial Plexus Injury

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Effect of augmented biofeedback for improvement of range of motion and upper extremity functionality in obstetric brachial plexus injury: a randomised control trial

International Journal of Therapy and Rehabilitation ◽

10.12968/ijtr.2019.0027 ◽

2020 ◽

Vol 27 (3) ◽

pp. 1-11

Author(s):

Reham Saeed Alsakhawi ◽

Azza Mohamed Atya

Keyword(s):

Physical Therapy ◽

Brachial Plexus ◽

Range Of Motion ◽

Upper Limb ◽

Brachial Plexus Injury ◽

Control Group ◽

Functional Activities ◽

Obstetric Brachial Plexus ◽

Therapy Programme ◽

Obstetric Brachial Plexus Injury

Background/Aims The loss of mobility and functional activities of the upper limb are the main longstanding complications of obstetric brachial plexus injury. The aim of this study was to investigate the effect of the augmented biofeedback system in conjunction with traditional physical therapy on the range of motion and functional activities in children with obstetric brachial plexus injury. Methods A total of 45 children aged from 6 to 10 years with obstetric brachial plexus injury were assigned into two groups. The control group received a traditional physical therapy programme, and the study group received the same programme with augmented biofeedback for 6 weeks. The main outcome parameters were the upper limb active range of motion, Mallet scale and Active Movement scale. Results The children in the study group showed greater significant improvement in all measured parameters compared with those in the control group. Conclusions Adding augmented biofeedback to the physical therapy programme provided greater improvement in upper limb mobility and functional activities for children with obstetric brachial plexus injury children.

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