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Brachial Plexus Neuropathy ACTA ORTHOPAEDICA et Author’ s tr anslation TRAUMATOLOGICA Acta Orthop Traumatol Turc 2007;41(1):74-79 TURCICA Brachial plexus neuropathy (stinger syndrome) occurring in a patient with shoulder laxity Omuz laksitesi zemininde gelişen brakiyal pleksus nöropatisi (stinger sendromu): Olgu sunumu Mehmet Can UNLU,1 Hayrettin KESMEZACAR,2 Isik AKGUN2 1Private Duygu Hospital, Department of Orthopedics and Traumatology; 2Istanbul University, Cerrahpasa Faculty of Medicine, Department of Orthopedics and Traumatology Brakiyal pleksusun traksiyon veya kompresyon yaralan- The stinger syndrome is a common neuropathy caused by masına bağlı gelişen sık bir nöropati olan stinger sendro- traction or compression of the brachial plexus. In general, it mu genellikle sporcu genç erişkinlerde görülür ve etyo- is seen in young adults involved in sport activities and a lojisinde majör bir kontak travma bulunur. İki taraflı gle- major contact trauma is the rule. An 11 - y e a r-old boy with nohumeral eklem laksitesi olan 11 yaşındaki erkek hasta, bilateral glenohumeral joint laxity had pain in the left shoul- koşarken sol omuz ekstansiyonda iken, boynun karşı ta- d e r, numbness and decreased strength in the left arm that rafa minimal lateral fleksiyonu ile duvara çarptıktan son- developed after striking against a wall while running, with ra sol omuzda ağrı, sol kolda uyuşukluk ve kuvvet kaybı the left shoulder in extension and the neck in minimal later- yakınmalarıyla başvurdu. Hastanın sol omzunda, nötral al flexion to the contralateral side. Physical examination rotasyonda humerus başının anteroinferior doğrultuda showed extreme anteroinferior passive translocation of the ciddi derecede pasif translokasyonu ve sulkus bulgusu humeral head in neutral rotation and a positive sulcus sign vardı. Hastaya omuz laksitesi zemininde traksiyona bağlı in the left shoulder. The diagnosis was made as brachial brakiyal pleksus nöropatisi (stinger sendromu) tanısıyla plexus neuropathy (stinger syndrome) resulting from trac- omuz kol askısı verildi. İkinci haftadaki muayenesinde tion trauma and shoulder joint laxity and a shoulder- a r m sağ deltoid, supraspinatus ve infraspinatus kaslarında at- brace was applied. After two weeks, atrophy was detected rofi saptanması üzerine aktif ve pasif harekete yönelik in the right deltoid, supraspinatus, and infraspinatus mus- omuz egzersizlerine başlandı. Üç ay sonra yapılan kont- cles, and active and passive motion exercises of the shoul- rolde aktif eklem hareketleri açık ve kas kuvvetleri nor- der were initiated. At the end of three months, he achieved mal bulundu. normal range of motion of the shoulder and muscle strength. Anahtar sözcükler: Brakiyal pleksus/yaralanma; eklem insta- Key words: Brachial plexus/injuries; joint instability/complica- bilitesi/komplikasyon; omuz eklemi/yaralanma. tions; shoulder joint/injuries. Traction injuries, postirradiation injuries, local and seen in patients with Ehlers-Danlos syndrome.[ 2 ] J o i n t metastatic tumours, some hereditary and idiopathic laxity is not mentioned as a risk factor. In this paper we disorders can result in brachial plexus neuropathy. reported a child who had bilateral glenohumeral joint Stinger syndrome is seen mostly in young adults who laxity and who was referred with brachial plexus neu- participate in sport activities; traction or compression ropathy due to traction injury which occurred with the of the brachial plexus caused by contact trauma is the minimal lateral flexion of the neck to the opposite site etiologic factor.[ 1 ] Traction injuries due to joint laxity when the shoulder is inferiorly depressed in extension. without a major trauma are relatively rare and can be Correspondence to: Dr. Hayrettin Kesmezacar. Abide-i Hurriyet Cad., Ruyam Palas, No: 144/16, 34381 Sisli, Istanbul. Phone: +90 212 - 414 34 38 Fax: +90 212 - 414 34 38 e-mail: [email protected] Received: 08.08.2005 Accepted: 16.02.2006 Unlu et al. Brachial plexus neuropathy (stinger syndrome) occurring in a patient with shoulder laxity 75 Case report to the level of T7 were noted. Moderate passive An eleven years old boy without previously translocation of the humeral head to anteroinferior known disorder attained to hospital with pain in the direction in neutral rotation was also observed in the left shoulder, numbness and weakness in the left arm right shoulder. Systemic examination and laboratory that developed after striking against a wall while findings (C-reactive protein, erythrocyte sedimenta- running, with the left shoulder in extension and the tion rate, and blood count) were normal; no osseous neck in minimal lateral flexion to the contralateral pathology in the roentgenograms and no generalized side (figure 1). Upper extremity muscle strength joint laxity were found. The diagnosis was made as weakness was noted according to the MRC scale brachial plexus neuropathy (stinger syndrome) (Medical Research Council scale)[3]: deltoid (3/5), resulting from traction trauma and shoulder joint supraspinatus (3/5), infraspinatus (3/5), biceps laxity. A shoulder-arm brace was applied and further brachii (3/5), triceps (4/5), brachioradialis (4+/5), evaluation was ordered. In magnetic resonance wrist extensors (4+/5), wrist flexors (4+/5), abductor imaging (MRI) of the brachial plexus taken three pollicis brevis (4+/5), first dorsal interrossei (4+/5), days after the initial trauma, a minimal enlargement and abductor digiti minimi (4+/5). Diminished of the left 7th and 8th cervical root sheaths com- biceps and brachioradialis reflexes and winging of pared to the right side (an anatomic variation), fluid the scapula were also noted with no sensorial abnor- collection in the left glenohumeral joint and the sub- malities except of hypoesthesia and decreased two coracoid bursa, and pathological signal changes con- point discrimination in the lateral side of the shoul- sistent with trauma in T2 weighted images in left d e r. Sulcus sign as well as significant passive supraspinatus and infraspinatus muscles were found translocation of the humeral head to anteroinferior (figure 3a-c). Nerve conduction study and elec- direction (until the point of dislocation) in neutral tromyography (EMG) that were performed 11 days rotation were observed in the left shoulder (figure 2). after the initial trauma were normal in both upper The range of motion of the contralateral shoulder extremities except lower amplitudes for the com- was nor mal with active elevation of 185 degrees, bined action potential of the left musculocutaneous external rotation of 72 degrees and internal rotation nerve than the right one. Sensorial conduction and needle EMG studies were also found as normal. The control examination in the second week revealed atrophy of the left deltoid, supraspinatus and infra- spinatus muscles while the passive joint range of motion was normal. Then active and passive ROM exercises of the shoulder were initiated. After this Figure 1. Mechanism of injury: Shoulder in extension and the neck in mini- mal lateral flexion to the opposite Figure 2. The sulcus sign found during the s i t e . examination. 76 Acta Orthop Traumatol Turc time, the patient was followed with 2 weeks’ inter- ings are present, it should be considered as cervical vals. At the end of third month from the initial trau- fracture or spinal cord contusion until proved other- ma the control nerve conduction study and EMG wise. Clavicular fracture, shoulder dislocation and were normal, no atrophy was found, winging of the acromioclavicular joint separation should be included scapula related to weakness of serratus anterior mus- in the differential diagnosis.[ 4 ] There are 3 diff e r e n t cle was largely improved and the sulcus sign was mechanisms of trauma leading to this syndrome[ 5 , 6 ] : absent (figure 4a,b). Active joint motion and the muscle strength were normal (figure 5a,b). 1. The first mechanism is the traction injury of the brachial plexus; in this case, when shoulder is Discussion depressed, neck is forced to lateral flexion to the oppo- Stinger syndrome is a peripheral nerve injury- site side. brachial plexus neuropathy following neck and shoul- 2. The second mechanism is direct blow to the der trauma. This injury is generally self limited, of supraclavicular fossa. short duration, but improvement may take several months in severe cases.[ 4 ] The primary symptom is 3. The third mechanism is neck hyperextension burning and pain radiating from shoulder to the upper combined with a lateral flexion to the same side. extremity accompanied with numbness, paresthesia Cervical nerve root lesions are also reported along and weakness. The syndrome is mostly seen in athletes with upper trunk involvement in most cases.[ 5 , 7 ] following a major trauma.[ 1 ] Cervical fractures, dislo- Typically first or second degree of peripheral nerve cations and spinal cord contusion should first be injuries is present in this situation.[ 1 ] Neuropraxia is a excluded. When symptoms are bilateral; tenderness over the cervical vertebrae and lower extremity find- first degree injury where axonal integrity is spared, but nerve functions are disrupted due to demyelinization. ( a ) ( b ) ( c ) Figure 3. (a) Minimal enlargement of the left 7th and 8th cervical root sheaths in the cervical MRI, (b) fluid collection in the glenohumeral joint and the subcoracoid bursa in the axial view, (c) pathologic signal changes consisted with trauma are seen in the frontal images in supraspinatus and infra- spinatus muscles. Unlu et al. Brachial plexus neuropathy (stinger syndrome) occurring in a patient with shoulder laxity 77 ( a ) ( b ) Figure 4. (a)Winging of the scapula was largely improved; (b) appearance of the left shoulder with sulcus test. Axonotmesis is a second degree injury with axonal generally can be seen in the muscles innervated by the damage and Wallerian degeneration. Neurotmesis is a upper trunks (5t h and 6t h) of the brachial plexus. The third degree injury referring permanent nerve injury diagnosis can be confirmed, localization and the sever- and usually is not seen in the stinger syndrome. Wi t h ity of the lesion can be determined with electrodiag- the evaluation of muscle strength, specific nerve nostic studies.
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