A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report

Journal of Medical Case Reports, Jan 2017

Background Although open injuries involving the brachial plexus are relatively uncommon, they can lead to permanent disability and even be life threatening if accompanied by vascular damage. We present a case report of a brachial plexus injury in which the urgency of the situation precluded the use of any ancillary diagnostic examinations and forced a rapid clinical assessment. Case presentation We report a case of a Portuguese man who had a stabbing injury at the base of his left axilla. On observation in our emergency room an acute venous type of bleeding was present at the wound site and, as a result of refractory hypotension after initial management with fluids administered intravenously, he was immediately carried to our operating room. During the course of transportation, we observed that he presented hypoesthesia of the medial aspect of his arm and forearm, as well as of the ulnar side of his hand and of the palmar aspect of the last three digits and of the dorsal aspect of the last two digits. Moreover, he was not able to actively flex the joints of his middle, ring, and small fingers or to adduct or abduct all fingers. Exclusively relying on our anatomical knowledge of the axillary region, the site of the stabbing wound, and the physical neurologic examination, we were able to unequivocally pinpoint the place of the injury between the anterior division of the lower trunk of his brachial plexus and the proximal portion of the following nerves: ulnar, medial cutaneous of his arm and forearm, and the medial aspect of his median nerve. Surgery revealed a longitudinal laceration of the posterior aspect of his axillary vein, and confirmed a complete section of his ulnar nerve, his medial brachial and antebrachial cutaneous nerves, and an incomplete section of the ulnar aspect of his median nerve. All structures were repaired microsurgically. Three years after the surgery he showed a good functional outcome. Conclusions We believe that this case report illustrates the relevance of a sound anatomical knowledge of the brachial plexus in an emergency setting.

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A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report

Casal et al. Journal of Medical Case Reports A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report Diogo Casal 0 1 3 Teresa Cunha 1 Diogo Pais 0 3 Inês Iria 2 4 Maria Angélica-Almeida 0 1 3 Gerardo Millan 1 José Videira-Castro 1 João Goyri-O'Neill 0 3 0 Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa , Campo dos Mártires da Pátria, 130, 1169-056 Lisbon , Portugal 1 Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central , Lisbon , Portugal 2 UCIBIO, Life Sciences Department, Faculty of Sciences and Technology, Universidade NOVA de Lisboa , Caparica , Portugal 3 Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa , Campo dos Mártires da Pátria, 130, 1169-056 Lisbon , Portugal 4 CEDOC, NOVA Medical School, Universidade NOVA de Lisboa , Lisbon , Portugal Background: Although open injuries involving the brachial plexus are relatively uncommon, they can lead to permanent disability and even be life threatening if accompanied by vascular damage. We present a case report of a brachial plexus injury in which the urgency of the situation precluded the use of any ancillary diagnostic examinations and forced a rapid clinical assessment. Case presentation: We report a case of a Portuguese man who had a stabbing injury at the base of his left axilla. On observation in our emergency room an acute venous type of bleeding was present at the wound site and, as a result of refractory hypotension after initial management with fluids administered intravenously, he was immediately carried to our operating room. During the course of transportation, we observed that he presented hypoesthesia of the medial aspect of his arm and forearm, as well as of the ulnar side of his hand and of the palmar aspect of the last three digits and of the dorsal aspect of the last two digits. Moreover, he was not able to actively flex the joints of his middle, ring, and small fingers or to adduct or abduct all fingers. Exclusively relying on our anatomical knowledge of the axillary region, the site of the stabbing wound, and the physical neurologic examination, we were able to unequivocally pinpoint the place of the injury between the anterior division of the lower trunk of his brachial plexus and the proximal portion of the following nerves: ulnar, medial cutaneous of his arm and forearm, and the medial aspect of his median nerve. Surgery revealed a longitudinal laceration of the posterior aspect of his axillary vein, and confirmed a complete section of his ulnar nerve, his medial brachial and antebrachial cutaneous nerves, and an incomplete section of the ulnar aspect of his median nerve. All structures were repaired microsurgically. Three years after the surgery he showed a good functional outcome. Conclusions: We believe that this case report illustrates the relevance of a sound anatomical knowledge of the brachial plexus in an emergency setting. Brachial plexus; Brachial plexus injuries; Brachial plexus anatomy; Wounds and injuries; Peripheral nervous system; Neurological examination; Nerve repair; Case report - Background Although open injuries involving the brachial plexus (BP) are relatively uncommon nowadays, not only can they lead to permanent severe limb dysfunction, but they also might be life threatening, since many of these injuries are accompanied by vascular damage and sometimes even by lung injury [1–7]. In such emergency situations, immediate surgical exploration is necessary and there is consensus for simultaneous vascular and nerve repair [4, 8, 9]. Immediate nerve repair also minimizes the need for nerve grafts, flaps, or nerve reconstruction conduits [5]. Therefore, the only opportunity to assess and evaluate the patient is often during the transfer from the emergency department to the operating room. In these circumstances, clinical evaluation might be the only diagnostic tool and therefore plays a pivotal role in early diagnosis and surgical planning [4, 8, 9]. In fact, a summary medical history and a directed physical examination are in most cases sufficient to identify the level of injury, the nerves involved, and the severity of injury [8, 9]. However, it should be noted that in many cases of open wounds associated with major vascular bleeding, patients are too unstable for even a summary neurological examination to be made prior to transport to the operating room [10]. In fact, frequently patients are carried to the emergency room already under sedation and ventilated [8–10]. Depending on the severity and degree of vascular involvement, the urgency of these situations may even preclude the use of any ancillary diagnostic methods and force a rapid clinical assessment based on a sound knowledge of BP anatomy [10]. Even though there have been reports of BP lesions since at least the eighth century BC in Homer’s Iliad [11], even today the complexity, multiplicity, and pot (...truncated)


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Diogo Casal, Teresa Cunha, Diogo Pais, Inês Iria, Maria Angélica-Almeida, Gerardo Millan, José Videira-Castro, João Goyri-O’Neill. A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report, Journal of Medical Case Reports, 2017, pp. 6, 11, DOI: 10.1186/s13256-016-1162-6