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HPI
A 21-year-old male with a history of right upper extremity brachial plexus tractional injury (1 year prior) presents after a motor vehicle collision. He does not have normal sensation in the right arm but notes that the arm is floppy and feels that it is broken. He has baseline decreased sensation and weakness in the right arm. Other injuries include multiple left-sided rib fractures and a small pneumothorax.
PMH
PMH: Right upper extremity brachial plexopathy (1 year prior) PSH: ORIF right clavicle (1 year prior)
PE
Focused physical examination of the right upper extremity reveals an obvious deformity of the right arm without any open wounds. There is a well-healed scar over the right clavicle. He has 3/5 wrist extensors/flexors, 3/5 FDS/FDP, 3/5 I/O, 3/5 EPL, and 1/5 elbow flexion/extension. There is diffusely decreased sensation to light touch from C5-T1. He has 2+ RP and warm and well-perfused fingers.
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ORIF right humerus (supine, deltopectoral approach, Proximal humerus locking plate)