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CASE REPORT
Year : 2016  |  Volume : 16  |  Issue : 1  |  Page : 86-88

Brachial plexopathy, whiplash injury, and fracture humerus: An unhappy triad


Department of Orthopaedics, Acharya Vinoba Bhave Rural Hospital, Wardha, Maharashtra, India

Date of Web Publication7-Jan-2016

Correspondence Address:
Pradeep K Singh
Department of Orthopaedics, Acharya Vinoba Bhave Rural Hospital, Sawangi (M), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-6308.173478

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  Abstract 


Clinical picture of brachial plexopathy may be overlapped by concomitant presence of ipsilateral fracture of humerus. Compound fracture of proximal shaft of humerus in high-energy road traffic accident may completely mask the feature of brachial plexus injury, especially when a patient is under the influence of alcohol. We are reporting a case that sustained compound fracture of proximal shaft of humerus with missed brachial plexus injury which was evident 3 weeks after the trauma. The best of clinical services can lead to excellent functional outcome but cannot avoid medico-legal consequences.

  Abstract in Arabic 

اعتلال الضفيرة العضدية، الإصابة المصعية ، وكسر عظم العضد: ثالوث غير محمود
الصورة السريرية لاعتلال الضفيرة العضدية يمكن أن تتداخل مع وجود ما يصاحب ذلك من كسر في عظم العضد. كسر مركب من رمح القريبة من عظم العضد في الحوادث المرورية على الطرق السريعة المزدحمة
قد يخفي الحادث ميزة للإصابة الضفيرة العضدية تماما ، وخصوصا عندما يكون المريض تحت تأثير الكحول. هذه المقالة تصف حالة إصابة بكسر مركب في
رمح القريبة من عظم العضد مع إصابة الضفيرة العضدية اتضحت بعد ثلاثة أسابيع من الحادث. أفضل الخدمات السريرية يمكن أن تؤدي إلى نتائج وظيفية ممتازة ولكن لا يمكن تجنب عواقب الطب الشرعي.

Keywords: Brachial plexopathy, shoulder trauma, whiplash injury


How to cite this article:
Singh PK, Khan S, Singh G. Brachial plexopathy, whiplash injury, and fracture humerus: An unhappy triad. Saudi J Sports Med 2016;16:86-8

How to cite this URL:
Singh PK, Khan S, Singh G. Brachial plexopathy, whiplash injury, and fracture humerus: An unhappy triad. Saudi J Sports Med [serial online] 2016 [cited 2023 Feb 8];16:86-8. Available from: https://www.sjosm.org/text.asp?2016/16/1/86/173478


  Introduction Top


Most of the fractures of the humerus are inherently unstable, and associated open wound may adversely affect the outcome.[1] Simultaneous occurrence of compound fracture and brachial plexus injury are rare though high-energy trauma is the common factor in epidemiology of both the injuries. Brachial plexus lesions are known for causing significant physical disability and psychological distress. The clinical picture may get worse when brachial plexopathy associated with compound fracture of the humerus, and further is complicated by “whiplash associated disorder” later in the course. All existing pathology in one subject would carry more significance and relevance if occurs in a medical student who wishes to pursue his career in surgical fraternity. The uniqueness of this unhappy triad is brachial plexus injury, which was missed at the time of presentation that has clinical and medico-legal relevance.


  Case Report Top


A 22-year-old medical student, who was driving a car under the influence of alcohol, had a side-on collision with a bus. He was taken to the Department of Accident and Emergency immediately after injury with contaminated lacerated wound over the right proximal arm. He was resuscitated immediately as per protocol set by the Department of Accident and Emergency. In the secondary survey, a 7.5 cm × 5 cm contaminated lacerated wound was present over his right arm with fracture of right proximal humerus [Figure 1]a. Wound was muscle deep had ragged margins with mild contamination. Fracture of proximal diaphyseal humerus was evident and showed abnormal mobility and loss of transmitted movements. The patient was disoriented and drowsy. Computed tomography scan ruled out head injury component. Apparently, he did not suffer any other injury. Final impression was compound fracture proximal humerus Grade 3B (Gustillo and Anderson) with alcohol intoxication. Emergency debridement of lacerated wound and intramedullary nailing of fracture were planned. The hemogram showed parameters within normal limits. Blood chemistry clotting profile liver and kidney profile revealed no abnormality. The patient was taken for surgery within a golden hour of injury. Under endotracheal, general anesthesia, debridement and intramedullary interlocking nailing (stainless steel) was done. Wound was closed primarily after thorough debridement and cleaning. After 1 week, passive mobilization of right elbow and shoulder started. We discharged the patient with prescribed physiotherapy plan.
Figure 1: Radiograph showing a displaced fracture of the proximal shaft of humerus Type: A-2-1 (OTA Classification). (a) Postoperative radiograph after 18 months revealed complete union of the fracture. (b)

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After 3 weeks of injury, the patient demonstrated obvious wasting of muscles around his right shoulder and difficulty in the abduction of his arm. Tricky movements at scapulothoracic level were observed. The nerve conduction studies showed electrophysiological evidence of supraclavicular brachial plexopathy mainly involving C-5, C-6 nerve root along with injury to ipsilateral C-3, and C-4 spinal accessory nerve as evident from neurogenic picture of trapezius and sternocleidomastoid. Concentric electromyography (EMG) sampling was done in the right deltoid, right supraspinatus, infraspinatus, right biceps, right triceps, right trapezius, and right serratus anterior muscles. Motor unit recruitment patterns were reduced in the right trapezius, right supraspinatus, right infraspinatus, right sternocleidomastoid, and right rhomboideus muscles. Magnetic resonance imaging (MRI) of brachial plexus revealed unremarkable information as metallic implant was inside the body. The neurosurgeon was consulted, and conservative management for brachial plexus injury was offered to the patient. Physical therapy was instituted for 6 months to strengthen functioning muscles. Headache, neck pain, loss of concentration, and sleeplessness were associated complaints along with recovering picture of brachial plexopathy. Fracture and soft tissue healing was evident clinically and radiologically. At the last follow-up (18 months), radiograph showed complete union of fracture [Figure 1]b, but he still had wasting of supraspinatus, infraspinatus, rhomboideus, and trapezius [Figure 2]a and [Figure 2]b. Deltoid regained its bulk and function. No significant functional and cosmetic complaints were noted after that.
Figure 2: Clinical photographs of 22 year old medical student who sustained compound proximal diaphyseal fracture of the humerus with missed brachial plexopathy showing obvious wasting of the supraspinatus and the infraspinatus muscles (a). Clinical picture demonstrates asymmetry in the deltoid and the trapezius (b)

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  Discussion Top


Fractures of the shaft of the humerus constitute 1–3% bulk of all fractures.[2],[3],[4] Only, small percentages (2%) of humerus fracture are compound fractures.[5] Several epidemiological studies have been published on fracture humerus in adults, but none of them reported brachial plexus injury in association with diaphyseal fracture humerus.[5],[6] However, brachial plexus palsy and major nerve injury following proximal humerus fracture in patients, who are skeletally immature has been reported in 0.7% patients.[7] Adult brachial plexus injury with dislocation of the shoulder and proximal humerus fracture has also been mentioned in literature.[8],[9]

Brachial plexus lesions can result from a variety of etiologies, including birth injuries, penetrating injuries, falls, and motor vehicle trauma. High-speed motor vehicle accidents and the number of brachial plexus injuries continues to rise throughout the world.[10],[11],[12] Males are predominantly involved.[11] Lesions can be situated at any level from the base of the nerve roots to the division of the brachial plexus in the axillary region. Several types of lesions can be differentiated into supraclavicular lesions at the root or primary trunk level (75% of the cases), infra and retroclavicular lesions of the secondary trunk (10%), and lesions of the terminal branches (15% of the cases).[12]

In the supraclavicular region, traction injuries occur when the head and neck are violently moved away from the ipsilateral shoulder, often resulting in an injury to the C5 or C6 roots or upper trunk.[12]

A significant proportion of patients with whiplash injury experience psychosomatic dysfunction in the chronic course of disease. They demonstrate not only neck and arm pain or numbness but also headache, nausea, sleeplessness, and general vague symptoms.[12] Our case had headache and neck pain that can be explained as posttraumatic stress or part of chronic whiplash associated disorder.[13]

Clinical signs of brachial plexopathy may not be evident in the patient who sustained high-energy trauma and compound fracture of the humerus. A few of such victims are under the influence of alcohol; hence, make the clinical evaluation more difficult as in our case. Some prospective studies have concluded that in low-velocity trauma of proximal shoulder; an electromyogram can be used as a tool to investigate nerve lesions as a detection only by the clinical examination proved to be difficult.[14],[15] MRI is thought to be the best technique to demonstrate nerve root avulsion. However, unlike EMG, MRI does not allow visualization of distal lesions of the brachial plexus. Reversible (edema) and irreversible (demyelination) lesion to the trunk and cord is difficult to differentiate and may require EMG or late MRI.[16]

During management of such cases arise many unanswered questions like-should we make mandatory MRI and EMG to rule out brachial plexus injury in every patient sustaining high-energy trauma and fracture of proximal part of the humerus? or are such injuries common in orthopedics practice? To get answer to the above-mentioned questions, we suggest a need of prospective study on patients with high-energy trauma around the shoulder and associated symptomatic or asymptomatic brachial plexus injury, should be evaluated by MRI and EMG. Perhaps, such cases suggest us to include EMG and nerve conduction study in a trauma management protocol to avoid unnecessary clinical and medico-legal consequences.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lin J, Hou SM, Hang YS, Chao EY. Treatment of humeral shaft fractures by retrograde locked nailing. Clin Orthop Relat Res 1997;342:147-55.  Back to cited text no. 1
    
2.
Ward EF, Savoie FH, Hughes JL. Fractures of the diaphyseal humerus. In: Skeletal Trauma: Fractures, Dislocation, Ligamentous Injuries. Vol. 2. Philadelphia: Saunders; 1998. p. 1523-47.  Back to cited text no. 2
    
3.
Mann RJ, Neal EG. Fractures of the shaft of the humerus in adults. South Med J 1965;58:264-8.  Back to cited text no. 3
[PUBMED]    
4.
Balfour GW, Mooney V, Ashby ME. Diaphyseal fractures of the humerus treated with a ready-made fracture brace. J Bone Joint Surg Am 1982;64:11-3.  Back to cited text no. 4
[PUBMED]    
5.
Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus. An epidemiological study of 401 fractures. J Bone Joint Surg Br 2006;88:1469-73.  Back to cited text no. 5
    
6.
Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br 1998;80:249-53.  Back to cited text no. 6
    
7.
Hwang RW, Bae DS, Waters PM. Brachial plexus palsy following proximal humerus fracture in patients who are skeletally immature. J Orthop Trauma 2008;22:286-90.  Back to cited text no. 7
    
8.
Chillemi C, Marinelli M, Galizia P. Fracture-dislocation of the shoulder and brachial plexus palsy: A terrible association. J Orthop Traumatol 2008;9:217-20.  Back to cited text no. 8
    
9.
de Laat EA, Visser CP, Coene LN, Pahlplatz PV, Tavy DL. Nerve lesions in primary shoulder dislocations and humeral neck fractures. A prospective clinical and EMG study. J Bone Joint Surg Br 1994;76:381-3.  Back to cited text no. 9
    
10.
Doi K, Kuwata N, Muramatsu K, Hottori Y, Kawai S. Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand Clin 1999;15:757-67.  Back to cited text no. 10
    
11.
Doi K, Muramatsu K, Hattori Y, Otsuka K, Tan SH, Nanda V, et al. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results. J Bone Joint Surg Am 2000;82:652-66.  Back to cited text no. 11
    
12.
Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg 2005;13:382-96.  Back to cited text no. 12
    
13.
Bunketorp L, Lindh M, Carlsson J, Stener-Victorin E. The perception of pain and pain-related cognitions in subacute whiplash-associated disorders: its influence on prolonged disability. Disabil Rehabil 2006;28:271-9.  Back to cited text no. 13
    
14.
Visser CP, Tavy DL, Coene LN, Brand R. Electromyographic findings in shoulder dislocations and fractures of the proximal humerus: Comparison with clinical neurological examination. Clin Neurol Neurosurg 1999;101:86-91.  Back to cited text no. 14
    
15.
Visser CP, Coene LN, Brand R, Tavy DL. Nerve lesions in proximal humeral fractures. J Shoulder Elbow Surg 2001;10:421-7.  Back to cited text no. 15
    
16.
Vargas MI, Beaulieu J, Magistris MR, Della Santa D, Delavelle J. Clinical findings, electroneuromyography and MRI in trauma of the brachial plexus. J Neuroradiol 2007;34:236-42.  Back to cited text no. 16
    


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