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A Preventable Cause of Brachial Plexus Injury

Wong, David H. Pharm.D., M.D.*; Ward, Michael G. M.D.

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To the Editor:—
The article by Coppieters et al., “Positioning in Anesthesiology Toward a Better Understanding of Stretch-Induced Perioperative Neuropathies”1 was enlightening. We thought the readers of Anesthesiology might also be interested in a preventable cause of perioperative brachial plexus injury—operating room (OR) armboard malfunction.
A 66-yr-old, ASA 3, man was scheduled for abdominal-perineal resection. The patient's arm was secured to the armboard with a Velcro strap; the arm was abducted approximately 75°. After general anesthesia was induced in the supine position, he was repositioned for the surgical procedure. During repositioning, when the patient was moved caudally on the OR table, the armboard on which the patient's left arm was secured fell. Even though the incident was witnessed and the patient's arm was immediately supported, the weight of the OR armboard, about 3 kg, transiently pulled on the patient's left arm.
The operation proceeded uneventfully. Upon awakening, however, the patient complained of left arm numbness and weakness. Examination revealed neurologic deficits in the left C5–C7 nerve roots; 0/5 arm flexion, 2/5 arm extension, 2/5 hand grip, and numbness of the fingertips. One month after the event, an EMG/NCV study showed acute denervation of the left C5–6 nerves. With treatment, the patient's left arm sensation and function returned and matched his right arm in 24 months.
Inspection of the OR armboard revealed that the metal bracket which contacted the OR table rail system was damaged, resulting in an insecure connection. Inspection of all armboards in the OR disclosed four damaged armboards. These damaged armboards were removed from the OR.
We recommend that the readers of Anesthesiology inspect the OR armboards that they use. When attaching or manipulating an armboard, we suggest that it is a good idea to test the armboard's security by gently leaning on the armboard and attempting to move the armboard out of position, before securing the patient's arm to the armboard.
David H. Wong, Pharm.D., M.D.*
Michael G. Ward, M.D.
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1. Coppieters MW, Van De Velde M, Stappaerts KH: Positioning in anesthesiology: Toward a better understanding of stretch-induced perioperative neuropathies. A nesthesiology 2002; 97: 75–81

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