INCOMPLETE BRACHIAL PLEXUS INJURY CAUSED BY MASSIVE CALLUS FORMATION IN A HORSE RIDER - A RARE COMPLICATION FOLLOWING CLAVICULAR FRACTURE

Abstract

HISTORY A 35 year old jockey presented to our Accident & Emergency with a history of fall off a horse sustaining injuries to the chest and right shoulder. No history of Head injury. PHYSICAL EXAMINATION GCS 15/15, marked tenderness over the middle third of right clavicle and tenderness over the 7th,8th and 9th ribs on the right side with decreased air entry on the same side. Patient had dyspnoea. No neurological deficit TEST AND RESULTS X ray, right shoulder revealed a displaced fracture of the middle third clavicle and pneumothorax seen on chest x ray. INITIAL TREATMENT Broad arm sling, insertion of intercostal drainage tube. Patient discharged two weeks later with no neurology. REVIEW 2 months Swelling over the right clavicle and gradual progressive weakness of the entire upper limb. PHYSICAL EXAMINATION Nontender swelling over the right clavicle, marked weakness of shoulder abduction and wrist and finger extension. FURTHER TEST AND RESULTS X-ray revealed union of the fracture with massive callus. Nerve conduction study showed a postganglionic brachial plexus injury. WORKING DIAGNOSIS Secondary brachial plexus injury due to fracture clavicle. TREATMENT AND OUTCOMES Resection of part of the clavicle and the encroaching callus from the undersurface of clavicle. Patient had no improvement in the first week after surgery, but improved after the third week and had full recovery by the fifth month. CONCLUSION Neurological complications in clavicle fractures are uncommon. As a primary lesion it is caused by trauma itself. Secondarily neuology may develop due to massive callus compressing the brachial plexus. Resection of the clavicle would appear to be the treatment of choice to relieve compression. Only a few reports of the injury are available in the literature. This case is reported for its rarity.