Radial nerve palsy at the elbow following venipuncture-case report

High radial nerve palsy

High radial palsy is primarily associated with humeral shaft fractures, whether primary due to the initial trauma, or secondary to their treatment. The majority will spontaneously recover, therefore early surgical exploration is mainly indicated for open fractures or if ultrasonography shows severe nerve damage. Initial signs of nerve recovery may appear between 2 weeks and 6 months. Otherwise, the decision to explore the nerve is based on the patient's age, clinical examination and electroneuromyography, as well as ultrasonography findings. If recovery does not occur, an autograft is indicated only in younger patients, before 6 months, if local conditions are suitable. Otherwise, nerve transfers performed by an experienced team give satisfactory results and can be offered up to 10 months post-injury. Tendon transfers are the gold standard treatment and the only option available beyond 10 to 12 months. The results are reliable and fast.

Irreparable Radial Nerve Palsy Due to Delayed Diagnostic Management of a Giant Lipoma at the Proximal Forearm Resulting in a Triple Tendon Transfer Procedure: Case report and Brief Review of Literature

Background:

Non-traumatic radial nerve palsy (RNP) caused by local tumors is a rare and uncommon entity.

Methods:

A 62-year-old female presented with a left non-traumatic RNP, initially starting with weakness only. It was caused by a benign giant lipoma at the proximal forearm that was misdiagnosed over a period of 2 years. The slowly growth of the tumor led to an irreparable overstretching-related partial nerve disruption. For functional recovery of the patient, a triple tendon transfer procedure had to be performed.

Results:

Four months after surgery, the patient was completely able to perform her activities of daily living again. At the 10-months follow-up, strength of wrist extension, thumb's extension and abduction, and long fingers II-V extension had all improved to grade 4 in Medical Research Council scale (0-5). In order to restore motion, the patient reported that she would undergo the same triple tendon transfer procedure a second time where necessary. Due to the initially misdiagnosed tumor, there was an overall delayed duration of time for functional recovery of the patient.

Conclusion:

The triple tendon transfer procedure offers a useful and reliable method to restore functionality for patients sustaining irreparable RNP. However, it must be noted critically with our patient that this procedure probably would have been avoided. Initially, there was weakness only by entrapment of the radial nerve. RNP caused by local tumors are uncommon but known from the literature, and so it should be considered generally in differential diagnosis of non-traumatic RNP.

Surgical management and outcome of iatrogenic radial nerve injection injuries

OBJECTIVE

Iatrogenic injury to the radial nerve can occur following intramuscular or intravenous injections of the upper extremity. In this study, we review the injury mechanism, operative techniques, and outcomes of patients evaluated for radial nerve injection injuries.

METHODS

Data from 33 patients evaluated by the senior authors (DGK and DHK) from 1970-2011 with radial nerve injection injuries were reviewed retrospectively. All patients had injury of the nerve during injection. All corrective operations involved the use of direct intraoperative nerve action potential (NAP) recordings and either neurolysis, neurectomy, or suture/graft repair. The Louisiana State University Health Science (LSUHS) grading system was used for clinical assessment.

RESULTS

Of the 33 patients, 23 underwent surgical intervention for persistent neurological deficit and/or pain. Of the 24 patients evaluated for injuries at the arm level, 17 required surgical exploration and repair for persistent symptoms. Nine patients required external neurolysis because the lesions were in continuity and positive NAP recording was across the lesion. All of these patients achieved a Grade 4 or better in functional recovery. Eight patients with lesions in continuity but in which NAP could not be recorded underwent either end-to-end suture (7) or graft repair (1) following resection of a 3.0 cm non-recordable segment. All patients achieved Grade 3 or 4 functional recovery. Six patients with forearm injuries involving the superficial sensory branch of radial nerve underwent either neurolysis (3) or neurectomy (3).

CONCLUSIONS

Surgical exploration may be indicated when pain or disabling motor deficits persist. Early diagnosis and operative intervention can achieve favorable outcomes through exploration and radial nerve repair.

Donor Hemovigilance with Blood Donation

BACKGROUND

Reports on unexpected events (UEs) during blood donation (BD) inadequately consider the role of technical UEs.

METHODS

Defined local and systemic UEs were graded by severity; technical UEs were not graded. On January 1, 2008, E.B.P.S.-Logistics (EBPS) installed the UE module for plasma management software (PMS). Donor room physicians entered UEs daily into PMS. Medical directors reviewed entries quarterly. EBPS compiled data on donors, donations, and UEs from January 1, 2008 to June 30, 2011.

RESULTS

6,605 UEs were observed during 166,650 BDs from 57,622 donors for a corrected incidence of 4.30% (0.66% local, 1.59% systemic, 2.04% technical UEs). 2.96% of BDs were accompanied by one UE and 0.45% by >1 UE (2-4). 6.3% of donors donating blood for their first time, 3.5% of those giving blood for their second time, and 1.9% of donors giving their third or more BD experienced UEs. Most common UEs were: discontinued collections due to venous access problems, repeated venipuncture, and small hematomas. Severe circulatory UEs occurred at a rate of 16 per 100,000 BDs.

CONCLUSIONS

Technical UEs were common during BD. UEs accompanied first and second donations significantly more often than subsequent donations.

Donor Hemovigilance during Preparatory Plasmapheresis

BACKGROUND

Reports on unexpected donor events (UEs) during preparatory plasmapheresis (PPP) are scarce, and rarely consider technical UEs.

METHODS

Defined local and systemic UEs were graded by severity; technical UEs were not graded. On January 1, 2008, E.B.P.S.-Logistics (EBPS) installed the UE module for plasma management software (PMS). Donor room physicians entered UEs daily into the PMS. Medical directors reviewed entries quarterly. EBPS compiled data on donors, donations and UEs from January 1, 2008 to June 30, 2011.

RESULTS

66,822 UEs were observed during 1,107,846 PPPs for a corrected incidence of 6.55% (1.4% local, 0.55% systemic, 4.6% technical UEs). 3.36% of PPPs were accompanied by 1 UE and 1.18% by >1 UE (2-5). 13.7% of donors undergoing PPP for the first time, 9.7% of those having a second PPP and 4.0% of those having a third or more PPPs were associated with UEs. Most common UEs were repeated venipuncture, and broken-off collection due to venous access problems and small hematomas. Severe systemic UEs occurred at a rate of 36 per 100,000 PPPs.

CONCLUSIONS

Technical UEs were common with PPP. UEs accompanied first and second donations significantly more frequently than for subsequent donations.

Procedure-oriented sectional anatomy of the elbow

This is the second in a series of papers related to procedure-oriented joint anatomy. This article will review the anatomy of the elbow and its relationship to procedures in the clinical setting. Needle procedures of the elbow joint include medial and lateral epicondyle injections, olecranon bursa injection, elbow joint aspiration, phlebotomies in the antecubital fossa, and intramuscular injections such as trigger point and botulinum toxin injections. Complications related to these procedures include infection, skin atrophy, injuries to peripheral nerves, tendon rupture associated with the use of corticosteroids, iatrogenic vascular injuries, and chronic local pain. This article provides anatomically accurate schematics of the elbow anatomy relevant to needle procedures. Cross-sectional anatomical schematics of the elbow were drawn as they appear on axial and coronal projections. Superficial and deep landmarks are highlighted as well as sources of potential complications. These schematics allow for safer and more accurate needle procedures in the elbow area, for both nonguided and musculoskeletal ultrasound-guided techniques.

Paresthesia and forearm pain after phlebotomy due to medial antebrachial cutaneous nerve injury

BACKGROUND

Although phlebotomy is a common procedure, there is limited information concerning to documented complications of venipuncture.

CASE PRESENTATION

A 45 year old left- handed woman was refered for elecrodiagnostic study with dysesthesia and pain in left medial forearm. She noted these symptoms three weeks after phelebotomy. Electrodiagnostic study showed severe involvement of left side Medial Antebrachial Cutaneous nerve (MAC nerve).

CONCLUSION

Phelebotomy is a cause of MAC nerve injury. Electrodiagnostic testing can be helpful in evaluating cases of sensory disturbance after phlebotomy.

Lateral antebrachial cutaneous nerve injury induced by phlebotomy

BACKGROUND

Phlebotomy is one of the routine procedures done in medical labs daily.

CASE PRESENTATION

A 52 yr woman noted shooting pain and dysesthesia over her right side anterolateral aspect of forearm, clinical examination and electrodiagnostic studies showed severe involvement of right side lateral antebrachial cutaneous nerve.

CONCLUSION

Phlebotomy around lateral aspect of antecubital fossa may cause lateral antebrachial cutaneous nerve injury, electrodiagnostic studies are needed for definite diagnosis.

Nerve injuries about the elbow

Multiple neurovascular structures may be at risk during injuries or procedures about the elbow joint. An appreciation of the complex anatomy of the region, the appropriate evaluation procedures and processes to diagnose injury, and an understanding of treatment options are necessary for surgeons who treat elbow injuries. This article reviews the anatomy, diagnosis, and treatment options of injuries to neural structures about the elbow.

Closed partial rupture of a common digital nerve in the palm: a case report

Nerve injuries in the upper extremity after trauma are common. Typically nerve damage is the result of traction, crush injury, ischemic insult, or direct laceration of the peripheral nerve. Examination of the literature shows that nerve damage in closed traumatic injury is much less common than in open trauma, especially when this standard is applied to closed nerve injuries distal to the wrist. We report a case of closed partial neurotomy of a common digital nerve.

Phlebotomy-related lateral antebrachial cutaneous nerve injury

Although phlebotomy is a common and widespread procedure, the medical literature provides limited information in terms of the documented complications of venipuncture. Documentation of phlebotomy-related nerve injuries is even more limited. The authors present a case report of a phlebotomy-induced lesion of the lateral antebrachial cutaneous nerve. According to our literature search, this is the first case in which electrodiagnostic studies were used to document venipuncture-related injury of the lateral antebrachial cutaneous nerve. Specific electrodiagnostic testing is used to definitively diagnose this rare injury and to track recovery. Electrodiagnostic testing can be helpful in evaluating cases of sensory disturbance after phlebotomy.

Radial nerve injury after routine peripheral vein cannulation

The dorso-radial aspect of the wrist and hand is a common location for intravenous (IV) cannulation prior to anesthesia. The sensory branch of the radial nerve lies superficially in this area, and it can be injured during routine insertion of IV catheters. In this case, the nerve was lacerated during insertion and a painful neuroma developed after elective surgery and anesthesia. Knowledge of this complication may help with its recognition and treatment.

Radial nerve rupture after a traction injury: a case report

A case in which a patient sustained a closed rupture of the radial nerve at the lateral intramuscular septum from a traction injury is presented. No humeral fracture occurred, and the patient regained substantial function after delayed primary repair.

Apparent weakness of median and ulnar motors in radial nerve palsy

Muscle testing of a patient with radial nerve palsy can incorrectly suggest median and ulnar weakness because of a decreased ability to stabilize the thumb and wrist. Ten adult volunteers had radial nerve blocks and their strengths were quantitatively evaluated before and after blocking for grip, key pinch, isolated thumb adduction (adduction pinch), thumb palmar abduction, finger flexion, and flexor pollicis longus (FPL) function. Data were analyzed by paired t test (p less than 0.05). All composite motions that required stabilization of the wrist or thumb showed marked weakness after the radial nerve block (grip decreased 77%, key pinch decreased 33%, and thumb palmar abduction strength decreased 53%). The strength of adduction pinch, finger flexion, and FPL showed no significant decreases after the radial nerve block. Since adduction pinch and isolated FPL function can be easily tested clinically, they should be examined to prevent confusion with median and ulnar problems.