i
A 34-Year Old Male With Traumatic Right Total Preganglionic Brachial Plexus Injury : A Case Report
Oleh:
Residen Stase Hand Februari 2019 Angga Nugraha P.J
Ivander Purvance G Agung Krisna Yuda
Alit Satria Nugraha Claudia Santosa
Pembimbing:
dr. Made Bramantya Karna, Sp.OT (K)
PROGRAM PENDIDIKAN DOKTER SPESIALIS ORTHOPAEDI TRAUMATOLOGI
DEPARTEMEN ILMU BEDAH
FAKULTAS KEDOKTERAN UNIVERSITAS UDAYANA RSUP SANGLAH
DENPASAR
2019
i Table of Content
Abstract……….………..…….………...1
Introduction……….……….………...1
Anatomy of brachial plexus………..……….………...3
Case Presentation………...……….………..……..3
Initial Evaluation………....…….3
Investigations…………...……….………....………3
Treatment…………....………..……...3
Discussion…………..………....………...…6
Conclusion…….………...….…....…7
References………...……….7
1 Abstract
Brachial plexus injury results in sudden damage of the nerves that control movement and sensation in the arm and hand, causing weakness to loss of sensation of the affected muscle.
Most traumatic brachial plexus injuries occur when the arm is forcefully pulled or stretched.
Brachial plexus injuries vary greatly in severity, depending upon the type of injury and the amount of force placed on the plexus are avulsion; in this most severe brachial plexus injury, the nerve root has been torn from the spinal cord. Our patient, a 34-year-old male, came with a presenting symptoms of total muscle function loss on upper right extremities resulted from an accident 7 years ago causing fractures on his right arm and shoulder, that have been treated with a surgery. EMG NVC was performed and showed a diganosis of right total preganglionic brachial plexus injury. Furthermore, the patient is planned to have FFMT Examination.
Keywords: brachial plexus injury, case report, trauma
Introduction
The brachial plexus is a network of intertwined nerves that control movement and sensation in the arms and hands. A traumatic brachial plexus injury involves sudden damage to these nerves, and may cause weakness, loss of feeling, or loss of movement in the shoulder, arm, or hand. Most traumatic brachial plexus injuries occur when the arm is forcefully pulled or stretched. Many events can cause the injury, including falls, motor vehicle collisions, knife and gunshot wounds, and most commonly, motorcycle collisions (Leiberman, 2014).
Brachial plexus injuries vary greatly in severity, depending upon the type of injury and the amount of force placed on the plexus are avulsion; in this most severe brachial plexus injury, the nerve root has been torn from the spinal cord. These types of injuries may not be repairable with surgery, stretch (Neuropraxia); when the nerve is mildly stretched, it may heal on its own or require simple, nonsurgical treatment methods to return to normal function, and rupture; a more forceful stretch of the nerve may cause it to tear partially or fully. These types of injuries can sometimes be repaired with surgery (Leiberman, 2014; Miller and Thompson, 2016).
The most common symptoms of brachial plexus injury include weakness or numbness, loss of sensation, loss of movement (paralysis), and pain. In addition, some patients display specific signs that help determine the location of the nerve injury, narrowing of the eye pupils, drooping
2 of the eyelid, and lack of ability for the face to sweat (Horner's syndrome) is a sign that the injury is close to the spinal cord and a shooting nerve-like pain when the doctor taps along the affected nerves (Tinel sign) suggests an injury farther from the spinal cord. Over time, if the location of the Tinel sign moves down the arm toward the hand, it is a sign that the injury is repairing itself (Solomon and Apley, 2010).
Imaging tests mostly done are X-rays; this imaging test creates clear pictures of dense structures, like bone. X-rays of the neck, chest, shoulder, and arm are taken to rule out associated fractures and Computed tomographic (CT) scan; this test is considered the most reliable test for detecting spinal nerve avulsion injuries. An Electrodiagnostic studies is also important; These tests measure nerve conduction and muscle signals. They are important evaluation tools because they can confirm the diagnosis, locate the nerve injury, characterize its severity, and assess the rate of nerve recovery (Moran, Steinmann and Shin, 2005; Sureka et al., 2009).
Many injuries to the brachial plexus will recover spontaneously without surgery over a period of weeks to months, especially if they are mild. Nerve injuries that heal on their own tend to have better functional outcomes. But, surgical treatment is typically recommended when the nerves fail to recover on their own or fail to recover enough to restore necessary function to the arm and hand. It is important to note that depending upon the severity of the injury, even surgery may not be able to return the arm or hand to preinjury abilities (Moran, Steinmann and Shin, 2005; Leiberman, 2014).
This study reported a case of right total preganglionic brachial plexus injury in the right upper extremity of an adult, resulting in plegia. A 34-year-old male had felt his right upper arm was weak and almost unable to move. He was suspected as having a brachial plexus injury by physical examination and sensoric examination. EMG NVC was performed and showed a diganosis of right total preganglionic brachial plexus injury. Thorough anamnesis and examination plays an important role here in establishing an accurate diagnosis.
3 Figure 1. Anatomy of brachial plexus (McRae, 2010)
Case Report
A 34-year-old male was unable to move his right upper extremity; he had traffic accident 7 years ago. He was riding a motorcycle then hit by a truck and fell down with his right shoulder bumped onto the asphalt. He was operated in Prima Medika Hospital because of fractures of his right shoulder and right arm in 2011. He realized that he couldn’t move his right upper extremity after the surgery. Patient was referred from Karangasem Hospital by an Orthopaedic Surgeon and diagnosed with Right Brachial Plexus Injury. At the initial visit, physical examination revealed weakness of right upper extremity, where the muscle power is zero (plegia) and the sensoric examination also showed C5 hypoesthesia, C6-C8 anesthesia, and T1-T2 anesthesia by dermatome. Plain X-ray images showed a plate and screw on the right middle clavicle and right distal humerus with an anterior dislocation of right humeral head. EMG NCV Examination was performed for a definitive diagnosis and showed a right total preganglionic brachial plexus injury. Afterwards, the patient was planned to have FFMT Examination.
4 Figure 1. Patient’s clinical appearance (17/2/18)
Table 1. Physical examination showing muscle power of right extremity is zero (plegia).
Figure 2. Sensoric examination was also shown C5 hypoesthesia, C6-C8 anesthesia, and T1-T2 anesthesia by dermatome
5 Figure 3. Plain X-ray images showed a plate and screw on the right middle clavicle with an
anterior dislocation of head of right humerus
Figure 3. Plain X-ray images showed a plate and screw on the right distal humerus
6 Discussion
Traction injuries commonly affect young men involved in motorcycle accidents. The grade of injury varies from lesions in continuity to either pre- or postganglionic rupture.
Supraclavicular injuries affect the upper roots, all the roots, or occasionally the lower roots only.
Infraclavicular injuries affect a combination of terminal branches (Hems, 2015). In our case presented here, the lesion was preganglionic.
Brachial plexus injuries vary greatly in severity, depending upon the type of injury and the amount of force placed on the plexus avulsed; in this most severe brachial plexus injury, the nerve root has been torn from the spinal cord. The most common symptoms of brachial plexus injury include, weakness or numbness, loss of sensation, loss of movement (paralysis), and pain.
In our case, the patient was unable to move his upper right extremity indicating paralysis, shown in the physical examination by a zero motor power. Furthermore, EMG NCV Examination was performed for a definitive diagnosis and showed a right total preganglionic brachial plexus injury. Afterwards the patient was planned to have FFMT Examination.
Some types of brachial plexus injuries may not be reparable with surgery, stretch (Neuropraxia); when the nerve is mildly stretched, it may heal on its own or require simple, nonsurgical treatment methods to return to normal function, and rupture; a more forceful stretch of the nerve may cause it to tear partially or fully. These types of injuries can sometimes be repaired with surgery. The patient, a 34-year-old male, was initially involved in a motorbike accident causing fractures on his right arm and right shoulder which then were treated with a surgery in 2011. Although, even after the surgery patient was unable to move his right upper extremity, indicating a brachial plexus injury. In traction injury of brachial plexus, spontaneous recovery is likely if the nerves are in continuity. With developments in recent years, restoration of shoulder and elbow movement can be expected at least for partial injuries. Results remain poor for nerves innervating forearm and hand muscles. Function may be improved by tendon transfer in patients with partial paralysis of the hand (Hems, 2015).
Unfortunately the incidence of traumatic brachial plexus injuries is increasing, leading to severe problems concerning quality of life in affected patients. Conservative treatment may help pain management and maintain some functionality or motion. Scientific and technical advances within recent years have significantly increased the importance of direct surgical operations such as neurolysis, nerve grafting, and nerve transfer, which, in combination with arthrodesis, tendon
7 transfer, or functioning free muscle transplantation, may improve any muscle functionality to at least some degree (Faraj and Zaghal, 2012).
Conclusion
Our case presented traumatic right total preganglionic brachial plexus injury. It is of great importance for the patient to know exactly the extent of injury, what he can expect from a surgical operation, and whether he may be able to participate actively in any type of rehabilitation. Factors that will influence the final result are the delay between the time of injury and surgical intervention, concomitant vascular injuries, the age of the patient, and the length of the nerve graft. Despite the surgical inventions done for this patient, the long-term outcomes require further investigations.
Reference
Faraj, W. and Zaghal, A. (2012) ‘Brachial plexus injury’, in Totally Implantable Venous Access Devices: Management in Mid- and Long-Term Clinical Setting. doi: 10.1007/978-88-470- 2373-4.
Hems, T. (2015) ‘Brachial Plexus Injuries’, in Nerves and Nerve Injuries. doi: 10.1016/B978-0- 12-802653-3.00093-2.
Leiberman, J. R. (2014) ‘AAOS Comprehensive Orthopaedic Review’, American Academy of Orthopaedic Surgeons. doi: 10.1016/j.ijrobp.2009.05.029.
McRae, R. (2010) Clinical orthopaedic examination. 6th Edition. Churchill Livingstone.
Miller, M. D. and Thompson, S. R. (2016) Miller’s review of orthopaedics. 7th Editio.
Philadelphia, USA: Elsevier.
Moran, S. L., Steinmann, S. P. and Shin, A. Y. (2005) ‘Adult brachial plexus injuries:
Mechanism, patterns of injury, and physical diagnosis’, Hand Clinics. doi:
10.1016/j.hcl.2004.09.004.
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Sureka, J. et al. (2009) ‘MRI of brachial plexopathies’, Clinical Radiology. doi:
10.1016/j.crad.2008.08.011.
