BRACHIAL PLEXUS INJURY FROM ANTERIOR SHOULDER DISLOCATION - AEROBICS

Abstract

HISTORY: A 59 year-old right hand dominant white female slipped and fell during aerobic exercise, sustaining a right shoulder injury as she tried to prevent her fall with an outstretched upper limb. On presentation to the Emergency Department she was noted to have an anterior-inferior shoulder dislocation, which was reduced without complications. Shortly following the injury she noticed persistent paresthesias and weakness in her right hand. She reported no other injuries, trauma, or previous history of similar symptoms. There were no reports of neck, elbow, contralateral limb, or bowel/bladder issues. She was seen for electodiagnostic consultation 10 days after her injury. PHYSICAL EXAMINATION: Patient was an age appropriate female in no acute distress. She held her right arm internally rotated and adducted, and was apprehensive of any manipulation. Active, passive, and resisted range of motion of the elbow, wrist, and hand were pain free. Manual muscle testing of the right upper limb revealed significant weakness in shoulder girdle muscles, however the exam was compromised due to pain. Further weakness was also noted on elbow flexion and extension, wrist flexion and extension, and finger abduction. There was more pronounced weakness in the median nerve distribution, especially involving the distally innervated muscles. Reflexes of the right biceps, triceps, and brachioradialis were 1+ compared with 2+ on the left side. Sensation throughout the limb was intact ot light touch and pin prick. Testing of the left upper limb did not reveal any neurological deficits. DIFFERENTIAL DIAGNOSIS: Brachial Plexopathy Nerve Root Avulsion Neural-gic Amyotrophy Cervical Radiculopathy Rotator Cuff Injury Multiple Nerve Pressure Palsies TESTS AND RESULTS: 2 View shoulder films showing successful reduction of dislocation. Electrodiagnortic study with evidence of brachial plexus injury to all three trunks, with aspects of axonal injury and neurapraxia. Active recruitment was seen in all muscles tested, except the distal median nerve innervated muscles. Nerve conduction studies had reduced distal SNAP amplitudes (50%) and CMAP amplitudes (50%) in tested median and ulnar nerves. WORKING DIAGNOSIS: Brachial pan plexopathy. TREATMENT AND OUTCOMES: Protection:sling Slow and gradually progressive rehabilitation program. Adequate pain control with NSAIDS and modalities Further imaging studies and repeat electrodiagnostic testing.