1431 - Pinning the brachial plexus: first rib fracture leading to traumatic brachial plexopathy in a high school wrestler

Case Diagnosis: A 15-year-old male who developed traumatic brachial plexopathy due to first rib fracture after experiencing a wrestling injury

Case Description: A 15-year-old male wrestler presented with acute right posterior shoulder pain when he attempted to push himself up off the mat after a traumatic impact during a wrestling match. He endorsed dyspnea and subjective postural asymmetry with rightward lean at time of injury. Same-day chest and right shoulder radiographs were unremarkable. At presentation to clinic nine days later, his posture had improved, though he continued to experience right posterior scapular pain and paresthesias. Pertinent exam findings included right scapular asymmetry with less defined musculature, tenderness to palpation of the right cervical paraspinal muscles and right medial scapular border, weakness with right shoulder abduction and elbow extension, and significant right-sided scapular dyskinesis. Sensation to light touch was preserved and Spurling’s test was negative.

Discussions: Cervical spine radiographs revealed fractures of the T1 spinous process and right first rib, which prompted further evaluation with magnetic resonance imaging (MRI) of the cervical spine, thoracic spine, and brachial plexus. Spinal MRIs were negative for any cervical pathology. Brachial plexus MRI noted edema involving the brachial plexus trunks adjacent to the first rib fracture, consistent with traumatic brachial plexopathy. At 3-week follow-up, his pain had significantly improved with relative rest. He endorsed right arm tremors and continued to have trace weakness with shoulder abduction and elbow extension. Physical therapy was prescribed to focus on scapular and cervical strengthening and stabilization. At 4-month follow-up, his upper extremity symptoms had mostly resolved.

Conclusions: This case highlights the importance of comprehensive and serial evaluations for post-traumatic neurologic deficits. It is imperative to maintain a broad differential when evaluating an athlete with neurologic deficits after trauma. With traumatic brachial plexus injuries, first rib fractures should be included in the differential diagnosis.