Department of Neurosurgery, University of Wisconsin, Madison, WI, USA
8.1 Case Presentation
A 25-year-old male was a victim of a motorcycle accident 2 months ago. He had fractures of the left radius and ulna for which he underwent open reduction and internal fixation, left scapular fracture, left pneumothorax , and concussion with a negative head CT . He was unable to move the left arm save for some finger wiggle. He had no feeling in the arm except some sensation in the hand. Over time he regained some function in the wrist and hand but not the shoulder or elbow. He also regained some sensation in the arm. His pain level is 7/10 on VAS . Examination of the left arm: trapezius , rhomboids , and serratus anterior are normal. There is no function in the pectoralis major, supraspinatus , infraspinatus , subscapularis , latissimus dorsi , deltoid , biceps brachii , triceps , supinator , wrist extension, EPL , finger extension at the MPJ. Wrist flexion is 4-, pronation 2, FPL 3, FDS 4+, FDP to second and third digits 4, FDP to fourth and fifth digits 2, APB 4, Op P 4, adductor pollicis 4, IO 4, ADQ 4, and lumbricals 4. There is diminished light touch sensation over C4, C6, C7, and C8, and absent sensation over C5. Deep tendon reflexes are 2+ and symmetric.
What tests are needed?
What is the plan of treatment?
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Figure 8.1. Left ptosis and miosis = Horner’s syndrome. This signifies brachial plexus avulsion (pre-ganglionic lesion).
EMG / NCS : Left brachial plexopathy predominantly involving upper and middle trunks, probably avulsion (denervation of cervical paraspinal muscles). This should not be ordered too soon after trauma (<2–3 weeks) to allow for denervation changes to be detectable. CT – myelogram of the cervical spine (or cervical MRI ):
Figure 8.2. CT -myelogram showing left pseudomeningoceles at C7, C8, and T1 (arrows). These are commonly associated with nerve root avulsions.
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