Brachial Plexus Injury Accompanying Glenohumeral Instability Case Report and Literature Review

Case Report

Austin J Orthopade & Rheumatol. 2014;1(1): 4.

Brachial Plexus Injury Accompanying Glenohumeral Instability Case Report and Literature Review

Zumwalt M1* and Wooldridge A1

1Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, USA

*Corresponding author: Zumwalt M, Department of Orthopaedic Surgery and Rehabilitation, Texas Tech University Health Sciences Center, 3601 4th Street, MS 9436 Lubbock, TX 79430, USA, Tel: 806-743-2465; Fax: 806-743-1305; Email: mimi.zumwalt@ttuhsc.edu

Received: August 04, 2014; Accepted: October 22, 2014; Published: October 27, 2014

Abstract

Glenohumeral instability is a frequent condition after traumatic shoulder dislocation. Concomitant peripheral nerve injury is common and typically involves the axillary nerve. We present an unusual case of persistent suprascapular and long thoracic nerve injury, with resultant scapulothoracic dyskinesia contributing to glenohumeral instability. The upper extremity neuropraxia was followed with “benign neglect” for spontaneous resolution, prior to the treatment decision of performing anterior capsulorrhaphy alone versus the combined procedure with latissmus dorsi transfer and/or neurosurgical intervention.

Keywords: Brachial plexus injury; Glenohumeral instability; Shoulder dislocation; Scapulothoracic dyskinesia

Introduction

Shoulder dislocations typically occur due to major blunt trauma, but can also be due to minor trauma [1-3]. In most instances the forces imparted are indirect rather than direct impact [4]. Approximately 95% of shoulders dislocate anteriorly [2,5]. Subsequent glenohumeral instability is due to injury to the labrum, capsule, and nerve damage affecting the scapulothoracic articulation [4,6]. While peripheral nerve injury is common, brachial plexus injury is rare and can contribute to persistent glenohumeral instability due to scapulothoracic dyskinesia [3,7,8]. In this paper, we report an unusual case of an 18-year-old female with anterior shoulder instability secondary to recurrent dislocations, and concomitant suprascapular plus long thoracic nerve neuropraxia contributing to scapulothoracic instability.

Case Presentation

18 year-old left-hand dominant female sustained a right anterior shoulder dislocation after being tackled five years prior. Two years later, she sustained a second dislocation during an overhead basketball pass. In the past year, she lifted a heavy backpack when her right shoulder dislocated anteriorly again. Since her most recent closed reduction, she has had continued shoulder pain and gross deformity about the shoulder girdle. Feelings of instability and painful subluxation in her right shoulder have interfered with her activities of daily living and prevented her from participating in overhead sports. She has undergone physical therapy rehab exercises without complete resolution of her symptoms. She was most concerned about the arm “hanging down, slipping in and out, and her shoulder blade sticking up.”

History

18 year-old left-hand dominant female sustained a right anterior shoulder dislocation after being tackled five years prior. Two years later, she sustained a second dislocation during an overhead basketball pass. In the past year, she lifted a heavy backpack when her right shoulder dislocated anteriorly again. Since her most recent closed reduction, she has had continued shoulder pain and gross deformity about the shoulder girdle. Feelings of instability and painful subluxation in her right shoulder have interfered with her activities of daily living and prevented her from participating in overhead sports. She has undergone physical therapy rehab exercises without complete resolution of her symptoms. She was most concerned about the arm “hanging down, slipping in and out, and her shoulder blade sticking up.”

Physical examination

Upper extremities with bilateral ligamentous laxity (mainly elbow hyperextension and inferior sulcus sign); right shoulder girdle with mild atrophy of both spinati; tender over the trapezius, anterior joint line, sternocleidomastoid and paracervical musculature; active total elevation 175 degrees; decreased internal plus increased external rotation as compared to the other side to mid-high thoracic levels; 4+/5 drop arm test; superomedial protraction of the right scapula and winging with push-up; negative Spurling’s, positive inferior sulcus and anterior apprehension signs, equivocal O’Brien’s, negative relocation test and posterior apprehension sign; anterior subluxation with the arm adducted and relocation with 90 degree elevation (Figure 1-3).