Gun-Shot wound in the neck resulting in Brachial Plexus Palsy

A 42 year old right handed male sustained gun shot injury in left side of his neck resulting in clavicular fracture and Upper Brachial Plexus paralysis. At the time of presentation 3 months after injury, he had loss of following functions

1. Shoulder abduction beyond 90 deg
2. Elbow flexion & extension
3. Wrist and finger extension
4. Partial FDS, partial FDP(index) and FCR & FPL

a

b

c

Preoperative view showing (a) Loss of elbow flexion and absent thumb flexion & finger extension (b & c) Loss of shoulder abduction beyond 90 deg and external rotation

Surgical finding and Reconstruction :

On exploration there was rupture at the level of anterior and posterior division of upper trunk. The supra scapular nerve was found intact. There was calus found at the site of clavicular fracture which was left undisturbed. The supra scapular nerve was neurolysed. The entire infra clavicular plexus was explored and reconstruction was carried out by using sural nerve graft as follows.

career

1. Anterior division - Musculo Cutaneous Nerve(1), Median Nerve(1)
2. Posterior division - Axillary Nerve(1), Radial Nerve (2)

Rupture at division level

After reconstruction with sural nerve graft

Sural nerve graft was harvested from both legs. At 16 months follow up he has good shoulder abduction, elbow flexion and extension and full range of hand function. He is gone back to work.

Postoperative result at 16 months showing good function

Discussion :

This is a case of combined injury. The impact of injury was around the clavicle at the level of division of upper trunk and middle trunk. The injury therefore spared the supra scapular nerve. The axillary nerve and the entire posterior cord was injured. The lateral cord component of the medial nerve was damaged resulting in partial loss of finger flexion and total loss of flexion of thumb. The reconstruction was carried out using nerve grafts between the divisions directly into the respective nerves. The anterior division is mainly responsible for flexion of elbow and fingers. The posterior division is responsible for extension of all the joints. As the reconstruction was done within three months of injury along with regular physiotherapy and electrical stimulation, the patient had good recovery in all the grafted nerves.

The Surgical Team

1. Dr. S Raja Sabapathy
2. Dr Hari Venkatramani
3. Dr Ravindra Bharathi
4. Dr James D’Silva

The Anaesthesia Team

1. Dr. Ravindra Bhat V

2. Dr. Venkateswaran G