July 2017

A 55-year-old man with left upper extremity weakness following a gunshot wound

History

A 55-year-old, right-hand dominant male presents to the outpatient clinic six weeks after suffering a gunshot wound to the left neck with persistent left upper extremity weakness.

Exam

• Cranial nerves intact, including symmetric shoulder shrug. Diffuse weakness of left  arm 0/5 Shoulder abduction, external rotation – shoulder passively subluxed. 1/5  elbow flexion and supination. 4/5 Weakness of elbow and wrist extension, intact grip    and interosseous.
• Well-healed entry wound in the left neck posterior to the SCM, midclavicular 2 cm    rostral to the clavicle.
• Absent C5 and C6 sensory.
 

Follow-up Physical Exam

• Three month follow–up.
• 0/5 shoulder abduction, 0/5 external rotation. 3 /5 elbow flexion.
• 5/5 wrist extension, triceps, finger flexors, and intrinsics.
• No change in sensory.
 
Imaging
 
CT Angiogram-evidence of previous extensive vascular injury intact stent and patient vascularity. C6 and C7 transverse process fractures. Retained bullet fragment lateral to the C7 transverse process. Distal occlusion of radial artery with intact ulnar artery and good collateral.
 

 

Electrodiagnostics

Questions

References:
Gunshot wounds involving the brachial plexus: surgical techniques and outcomes. Kim DH, Murovic JA, Tiel RL, Kline DG. J Reconstr Microsurg. 2006;22(2):67-72

Direct plexus repair by grafts supplemented by nerve transfers. Kline DG, Tiel RL. Hand Clin. 2005;21(1)55-69

Surgical Outcomes of the brachial plexus lesions caused by gunshot wounds in adults. Secer HI, Solmaz I, Anik I, Izci Y, et al.J Brachial Plex Peripher Nerve Inj. 2009;4:11

Penetrating injuries due to gunshot wounds involving the brachial plexus. Kim DH, Murovic JA, Tiel RL, Kline DG. Neurosurg Focus. 2004;16(5) E

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