T.D., a 16-year-old high school student, had a severe football accident 3 months before his admission. He sustained a right brachial plexus injury, resulting in a flail arm. He had no recovery and was on medication for neurologic pain. He reported that he had no feeling or motion in his right shoulder or arm. He had atrophy over the supraspinatus and infraspinatus muscles and also subluxation of his shoulder and atrophy of the deltoid. He had no active motion of the right upper extremity and no sensation. The rest of his orthopedic exam showed full ROM of his hips, knees, and ankles with intact sensation and palpable distal pulses as well as normal motor function. He was diagnosed with a possible middle trunk brachial plexus injury from C7. He was scheduled for an EMG, nerve conduction studies, and so matosensory evoked potentials (SSEPs). His diaphragm was examined under fluoroscopy to R/O phrenic nerve injury.

With middle trunk brachial plexus injury, damage to the subscapular nerve will interrupt conduction to the  ubscapularis and teres major muscles. Damage to the long thoracic nerve prevents conduction to the serratus anterior muscles. Injury to the pectoral nerves affects the pectoralis major and minor muscles.

T.D. was scheduled for a brachial plexus exploration with possible nerve graft, nerve transfer, bilateral sural (calf) nerve harvest, or gracilis muscle graft from his right thigh.

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