Nerve lesions after blunt trauma – the importance of a careful trauma survey

Abstract text (incl. references and figure legends)

A 23-years-old male presented to the emergency department after sustaining a motorbike accident.

He had pain, bruising and limited range of motion in his right shoulder, and an open fracture of the first metatarsal head of his left foot(fig.1). After the initial trauma survey, radiographs showed no bone fracture in his shoulder and a comminuted fracture of the metatarsal head with partial bone loss and 180º rotation of the fragment(fig.2).

He was taken to the operating room for debridement and fixation of his open fracture. His left foot developed wound necrosis after 2 weeks and later required skin grafting by the Plastic Surgery department.

His inability to fully move his shoulder was attributed to the blunt trauma and an arm sling was used for comfort.

Two weeks after the accident, in the outpatient clinic, the patient presented with muscle atrophy and hypoesthesia in his right deltoid, and subtle scapular winging. A plexus lesion was suspected and an urgent MRI was performed. He was referred to physical therapy at the same time. The MRI showed hyperintensity in the C5 root, but no avulsions or lesions in the plexus. Electromyography showed axonal lesion of the axillary nerve but no root or plexus alterations.

The patient had a positive clinical evolution, with full healing of his left foot and improved mobility of his shoulder, although he did not fully recover skin sensation over the deltoid.

Motorbike accidents often result in high energy trauma and can be associated with plexus and nerve lesions. This case illustrates the need for a careful initial evaluation and second look for hidden lesions. The need for urgent surgery of his right foot obscured his shoulder complaints, but fortunately, it was detected after only two weeks and the patient had a positive clinical evolution.

DOI: 10.1016/j.ocl.2013.06.011

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