Disclosures: Hanna Oh: Nothing to disclose

Case Description: Patient presented with diffuse right upper extremity pain and limited range of motion in right shoulder due to metastatic lesion invading the right brachial plexus. Progression of disease and radiation-induced changes to the area resulted in a right flail arm with associated lymphedema and right humeral subluxation. The severity of pain necessitated oral pain regimen including oxycodone, gabapentin, fentanyl patch, and steroids. Patient continued to decline neurologically to the point of trace movement in proximal arm and antigravity movement in distal arm. She was deemed not a surgical candidate for forequarter amputation or shoulder fusion due to risk of poor wound healing from irradiated tissue.

Setting: Outpatient Clinic

Patient: 52-year-old female with history of pulmonary embolus on anticoagulation and diffuse metastatic uterine leiomyosarcoma to spine, lung, pancreas, kidney, left deltoid, left thigh, and right supraclavicular fossa status post multiple resections and radiation therapy to right supraclavicular fossa, brachial plexus, T9, and L2 with progression of disease despite multiple lines of chemotherapy.

Assessment/Results: X-ray right shoulder: inferior subluxation of right glenohumeral joint; CT neck: heterogeneously enhancing soft tissue mass along the right brachial plexus possibly infiltrating the left C5-6 neural foramen and encasing the right vertebral artery; Electrodiagnostic studies: chronic diffuse right brachial plexopathy, myokymia indicating radiation induced injury, and right axillary neuropathy.

Discussion: She required a multidisciplinary treatment plan including pain medications, orthotic evaluation, and lymphedema, physical, and occupational therapy. A right arm sling/immobilizer provided comfort to offload the glenohumeral joint. She benefited from soft stockinette bandaging and manual lymphatic drainage. She also benefited from therapeutic exercises, education on modified shoulder positioning and adaptive strategies.

Conclusion: Consulting services included physiatry, pain management, orthopedic surgery, medical oncology, and radiation oncology. Given the complexity of her oncologic treatment and medical history, conservative treatments such as PT, OT, lymphedema therapy and bracing options were essential for pain relief.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/flail-arm-due-to-brachial-plexopathy-from-tumor-invasion/