title: A stab wound to the axilla illustrating the importance of brachial plexus anatomy in an emergency context: a case report.
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal. diogo_bogalhao@yahoo.co.uk.|Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal. diogo_bogalhao@yahoo.co.uk.
authors.forename: Diogo
authors.identifier: http://orcid.org/0000-0002-5537-9340
authors.initials: D
authors.lastname: Casal
authors.affiliation: Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
authors.forename: Teresa
authors.initials: T
authors.lastname: Cunha
authors.affiliation: Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal.
authors.forename: Diogo
authors.initials: D
authors.lastname: Pais
authors.affiliation: UCIBIO, Life Sciences Department, Faculty of Sciences and Technology, Universidade NOVA de Lisboa, Caparica, Portugal.|CEDOC, NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal.
authors.forename: Inês
authors.initials: I
authors.lastname: Iria
authors.affiliation: Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.|Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal.
authors.forename: Maria
authors.initials: M
authors.lastname: Angélica-Almeida
authors.affiliation: Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
authors.forename: Gerardo
authors.initials: G
authors.lastname: Millan
authors.affiliation: Plastic and Reconstructive Surgery Department and Burn Unit, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
authors.forename: José
authors.initials: J
authors.lastname: Videira-Castro
authors.affiliation: Anatomy Department, NOVA Medical School, Universidade NOVA de Lisboa, Campo dos Mártires da Pátria, 130, 1169-056, Lisbon, Portugal.
authors.forename: João
authors.initials: J
authors.lastname: Goyri-O'Neill
mesh_terms: D000328:Adult; D001132:Arm / Q000294:innervation; D001365:Axilla / Q000293:injuries* / Q000294:innervation; D001917:Brachial Plexus / Q000293:injuries* / Q000503:physiopathology; D020516:Brachial Plexus Neuropathies / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D006225:Hand / Q000294:innervation; D006801:Humans; D006987:Hypesthesia / Q000209:etiology* / Q000503:physiopathology / Q000601:surgery; D008297:Male; D008866:Microsurgery; D016896:Treatment Outcome; D014459:Ulnar Nerve / Q000293:injuries* / Q000601:surgery; D014951:Wounds, Stab / Q000150:complications* / Q000503:physiopathology / Q000601:surgery
keywords: Brachial plexus; Brachial plexus anatomy; Brachial plexus injuries; Case report; Nerve repair; Neurological examination; Peripheral nervous system; Wounds and injuries