The Value of Physiatric Consultation and Examination, Findings of Plexopathy and Diffuse Axonal Injury in a Trauma Patient with Arm Weakness :  A Case Report

Case Diagnosis: a 64 year old male with acute major multiple trauma

Case Description or Program Description: The patient was struck by a falling tree resulting in loss of consciousness, left arm pain, right lower extremity deformity, and extracranial occipital hematoma. Initial workup revealed proximal right femoral shaft fracture; however, initial CT head was without acute intracranial abnormality. Due to persistent cognitive and functional deficits, physiatry was consulted. The physiatrist noted right hemiparesis (with disproportionate right proximal arm weakness) on exam. MRI brain was recommended. Additionally, the physiatrist recommended EMG testing to evaluate proximal right arm weakness.

Setting: acute care hospital, outpatient clinic

Assessment/Results: MRI Brain revealed diffuse axonal injury (DAI). Electrodiagnostic testing revealed evidence of a right brachial plexopathy affecting the posterior cord, resulting in complete denervation of the right deltoid and partial denervation of the right triceps, brachioradialis, and extensor indicis.

Discussion (relevance): This case highlights the importance of the physical exam in identifying crucial diagnoses in a complex trauma patient; findings of right hemiparesis with disproportionate proximal arm weakness prompted further studies that identified 2 contributors to this weakness: DAI and plexopathy.

Conclusions: This case also demonstrates the importance of maintaining a high index of suspicion for TBI in trauma patients, with studies showing DAI has a prevalence of up to 30% in patients with negative initial CT scans. (1) It further demonstrates the importance of assessment for peripheral nerve injury in TBI, with studies finding PNI in 10- 34% of TBI patients. (2) (3)