605 - When Bullets Fly, Bones Break, and Hematomas Hide

Friday, February 23, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

DM

Diane N. Moya, DO

Resident Physician
Nassau University Medical Center
East Meadow, New York, United States

Co-Author(s)

RS

Raheel Shah, n/a

OMS IV
New York Institute of Technology College of Osteopathic Medicine
Glen Head, New York, United States
JL

Jack E. Leal, DO

Resident Physician
Nassau University Medical Center
East Meadow, New York, United States
AR

Aniroodh Reddy, MD

Resident Physician
Nassau University Medical Center
East Meadow, New York, United States
TP

Thomas Pobre, MD

Attending Physician
Nassau University Medical Center
East Meadow, New York, United States

Case Diagnosis: 28 year-old male with right tibia fibula fracture, and left distal femur fracture after gun-shot wound (GSW) status post right tibia intramedullary nail fixation (IMN), left distal femur open reduction and internal fixation (ORIF) presenting with bilateral distal upper extremity weakness secondary to bilateral antecubital fossa hematomas.

Case Description: During the patient's hospitalization, pain management included Gabapentin, Oxycodone, Tizanidine, and Cymbalta. Acute inpatient rehabilitation complicated by bilateral distal upper extremity weakness for which cervical spine CT was done with inconclusive results. Bilateral upper extremity CT revealed fluid collections likely from trauma or myonecrosis. Neurology was consulted and recommended delaying NCV/EMG due to potential mass. Plastic surgery advised elevating the upper extremities and implementing physical therapy, occupational therapy, and heat therapy. Interventional radiology noted myonecrosis without fluid collection. Follow-up EMG/NCV was planned in three weeks.

Discussions: The antecubital fossa, separates the upper arm from the forearm, defined by the brachioradialis, pronator teres, and a line connecting the humeral epicondyles. Its roof and floor consist of the bicipital aponeurosis and brachialis, respectively. Within it pass the radial nerve, biceps tendon, brachial artery, and median nerve. Trauma to the brachial artery is the main cause of antecubital fossa hematomas, which can compress these structures, causing motor weakness. Median nerve compression weakens wrist and finger flexion and thumb opposition, while radial nerve compression affects wrist and finger extension, often leading to paresthesias. Hematomas here can also compromise the biceps tendon, affecting elbow flexion and supination.

Conclusions: This case describes a patient with bilateral antecubital fossa hematomas. Prompt clinical and radiographic evaluation allows for early intervention to prevent further nerve damage. With continued rehabilitation, especially occupational therapy the patient experienced continued improvements in distal extremity strength, dexterity, and pain.