A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report.

BACKGROUND: Although open injuries involving the brachial plexus are relatively uncommon, they can lead to permanent disability and even be life threatening if accompanied by vascular damage. We present a case report of a brachial plexus injury in which the urgency of the situation precluded the use of any ancillary diagnostic examinations and forced a rapid clinical assessment. CASE PRESENTATION: We report a case of a Portuguese man who had a stabbing injury at the base of his left axilla. On observation in our emergency room an acute venous type of bleeding was present at the wound site and, as a result of refractory hypotension after initial management with fluids administered intravenously, he was immediately carried to our operating room. During the course of transportation, we observed that he presented hypoesthesia of the medial aspect of his arm and forearm, as well as of the ulnar side of his hand and of the palmar aspect of the last three digits and of the dorsal aspect of the last two digits. Moreover, he was not able to actively flex the joints of his middle, ring, and small fingers or to adduct or abduct all fingers. Exclusively relying on our anatomical knowledge of the axillary region, the site of the stabbing wound, and the physical neurologic examination, we were able to unequivocally pinpoint the place of the injury between the anterior division of the lower trunk of his brachial plexus and the proximal portion of the following nerves: ulnar, medial cutaneous of his arm and forearm, and the medial aspect of his median nerve. Surgery revealed a longitudinal laceration of the posterior aspect of his axillary vein, and confirmed a complete section of his ulnar nerve, his medial brachial and antebrachial cutaneous nerves, and an incomplete section of the ulnar aspect of his median nerve. All structures were repaired microsurgically. Three years after the surgery he showed a good functional outcome. CONCLUSIONS: We believe that this case report illustrates the relevance of a sound anatomical knowledge of the brachial plexus in an emergency setting.

Tumors of the brachial plexus in a tertiary referral center: a case series and literature review.

Introduction: Brachial plexus (BP) tumors are very rare tumors, with less than 800 cases been described in the literature worldwide since 1970. These tumors often present as local or radicular pain, with scant or no neurological deficits. These symptoms are shared by many other more common rheumatologic diseases, thus making their diagnosis difficult in most cases. Additionally, these tumors often present as lumps and are therefore biopsied, which carries a significant risk of iatrogenic nerve injury. Material and Methods: In this paper the authors describe their experience with the management of 5 patients with BP tumors followed up for at least 2 years. There were 4 males and 1 female. Median follow-up time was 41 ± 21 months. Average age at diagnosis was 40,0 ± 19,9 years. The most common complaints at presentation were pain and sensibility changes. All patients had a positive Tinel sign when the lesion was percussed. In all patients surgery was undertaken and the tumors removed. In 4 patients nerve integrity was maintained. In one patient with excruciating pain a segment of the nerve had to be excised and the nerve defect was bridged with sural nerve grafts. Results: Pathology examination of the resected specimens revealed a Schwannoma in 4 cases and a neurofibroma in the patient submitted to segmental nerve resection. Two years postoperatively, no recurrences were observed. All patients revealed clinical improvement. The patient submitted to nerve resection had improvement in pain, but presented diminished strength and sensibility in the involved nerve territory. Conclusion: Surgical excision of BP tumors is not a risk free procedure. Most authors suggest surgery if the lesion is symptomatic or progressing in size. If the tumor is stationary and not associated with neurological dysfunction a conservative approach should be taken.

Neurogenic thoracic outlet syndrome associated with cervical rib.

A true neurogenic thoracic outlet syndrome (TOS) associated with a cervical rib is considered extremely rare. The authors present their experience with 5 cases of true neurogenic TOS associated with a cervical rib. All patients were female and had a cervical rib confirmed radiographically pre-operatively. Average age was 34,8 years. Although all patients had been treated with several combinations of diverse drugs and a rehabilitation program before referral to surgery, all described their pain as intense and debilitating before surgical treatment. All patients had pre-operative electromyographic abnormalities. Patients were operated on via a supraclavicular approach and the cervical rib was resected. No intra-operative or postoperative complications were noted. Two years postoperatively, all patients mentioned improvement. However, only 2 were symptomless, and on no medication. In one patient there was significant improvement, and in the remaining 2 patients some residual pain persisted that had to be dealt with pharmacologically. All patients were able to resume their daily life activities. Recovery was poorer in the 2 patients that had been referred to surgery after a longer period of time since the beginning of symptoms.

Circumferential tracheal reconstruction for the functional treatment of airway compromise.

OBJECTIVES/HYPOTHESIS: The objective was to describe a surgical technique for replacement of long tracheal defects with a totally autologous free prefabricated cutaneous chondromucosal forearm tubular flap, applied to humans. STUDY DESIGN: Surgical reconstruction of the trachea. METHODS: A three-stage surgery was performed in a 25-year-old patient who presented with a long tracheal defect not resolved by previous resection with primary anastomosis and laser surgery. RESULTS: The staged surgery has been well tolerated by the patient, and no problems at all were reported. The postoperative computed tomography scan and the bronchofibroscopy examination of the "neo-trachea" at 2 and 6 months revealed normal caliber, good healing of the suture lines, absence of crusts or granulation tissue, and a well-vascularized internal mucosal lining. CONCLUSION: The modified flap reconstruction technique has the potential to be considered reliable for the definitive circumferential reconstruction of extensive laryngotracheal defects not amenable to being cured by conventional techniques.

Hipertensión pulmonar en los pacientes con infección por el virus de la inmunodeficiencia humana. Estudio de 14 casos / Pulmonary hypertension in patients with human immunodeficiency virus infection. Study of 14 patients

Fundamento: En pacientes positivos para el virus de la inmunodeficiencia humana (VIH) se han descrito casos de hipertensión arterial pulmonar y cor pulmonale con hallazgos similares a los observados en la hipertensión arterial pulmonar primaria. Población y métodos: Se analizaron retrospectivamente 14 enfermos positivos para el VIH con datos ecocardiográficos de hipertensión arterial pulmonar diagnosticados durante 9 años (1991-1999). Resultados: El tiempo medio hasta el diagnóstico fue de 4 meses (límites, 1 semana-1 año). La hipertensión arterial pulmonar se consideró leve en 3 casos (23 por ciento), moderada en siete (54 por ciento) y grave en cuatro, con un valor medio del gradiente VD-AD de 57,96 mmHg (límites, 35-87). Se realizó terapia convencional en 10 casos, con progresión de la enfermedad en cinco. En éstos se empleó carvedilol con respuesta favorable en cuatro. Tres enfermos no requirieron tratamiento farmacológico. La evolución a largo plazo fue buena con mejoría clínica y ecocardiográfica en 11 casos (78 por ciento). El tiempo medio de seguimiento fue de 2 años (límites, 1-8 años) y fallecieron 3 pacientes (22 por ciento). Conclusiones: La hipertensión arterial pulmonar en los pacientes con infección por el VIH suele ser de grado moderado-grave y, sin un alto índice de sospecha, se produce un acusado retraso en el diagnóstico. El carvedilol podría ser una buena alternativa terapéutica en los casos de hipertensión arterial pulmonar refractaria a otros tratamientos. (AU)