The patient came to the clinic 22-October-2011 complaining of complete non-function of the right radial, ulnar and median nerves after cut wound right brachial brachial plexus through the deltoid muscle and proposed graft of the alleged cut subclavian artery 30-August-2011.

The patient performed 2 EMG with EC studies the last 19-October-2011 confirming that the mentioned nerves are completely non-functioning.

On examination: the right MCN is completely normal. The right axillary nerve also normal. The radial, ulnar and median are completely silent. There is severe causalgia when touching the right hand.

The old approach was refreshed and extended down to expose the ulnar and median nerves below the lesion. There is massive scar and neurolysis was performed with difficulty , especially the median which was buried in an arterial net , which is the graft which was harvested from the right femoral area. It was above the median nerve and was draining to various venous channels superior. The wound was extended superiorly to expose the cords and the subclavian artery. The posterior, lateral and medial cords were identified and also their branches and studying them with ISIS High-Line using the brachial plexus set, it was possible to see that the axillary, MCN and the triceps muscle are responding well after their neurolysis. The artery was normal at this level.  Continuing dissection down and up and from all directions, it became clear, that the subclavian artery is not torn and the graft was stitched to one of its branches, going superiorly engulfing the nerves and draining to the veins. The artery was inspected form the most proximal down to the most distal part. It is functioning well and there is no graft between them. The arterialized venous graft was dissected off and coagulated to prevent it from harming the nerves. All the running nerves were looking healthy and there is no ganglion, nor atrophy or disconnection. Several time revision was performed to ensure that there is no missing data. The retrograde stimulation of the right median nerve took place at the end of the operation, that it could elicit the right MCN. 

Routine closure of the wound.  Smooth postoperative recovery.

The patient came 26-June-2012 with signs of full recovery of the MCN. radial nerves. The patient can dorsiflex the wrist, but has minimal dorsiflexion of the fingers due to spastic pattern. The brachioradialis muscle is 5/5. All the proximal muscles of the forearm are functioning, which means that, despite the severe damage of the median and ulnar nerves, but they start to recover. The patient was advised to continue more aggressive physiotherapy to prevent contracture of the MPJs of the hands.

The patient got stab wound injury to the right brachial plexus. The graft of the cut subclavian artery misled the speculation and the proper planning for surgery. The artery and running nerves were not cut. It is mostly that the arterialized venous graft was playing a negative role in the recovery process of the nerves.

Neurolysis and elimination of the arterialized venous fistula which was engulfing all the nerves is mandatory in this case.

It became retrospectively clear, why the patient was complaining of causalgia. It is due to arterial engulfment of the nerves running at the involved site.

It took me 5 hours to understand that the subclavian artery was not grafted and the graft was between one of the small distal branches of the brachial artery and one of the veins proximally.

Such a case is not reported in the literature to my knowledge.