An uncommon peripheral nerve injury after penetrating injury of the forearm: the importance of clinical examination

Neglected posterior interosseous nerve injury

Posterior interosseous nerve (PIN) injury is uncommon due to its anatomically deep location. We report a neglected, rare case of PIN injury presenting the loss of extension of thumb, index, and small fingers with weakness of thumb abduction in a 49-year-old male patient. The patient sustained a penetrating injury to his right forearm caused by a kitchen knife that was repaired primarily through an emergency surgery under general anesthesia. During the regular follow-up on the 52nd postoperative day, the patient presented 20° of extension lags in the right thumb and index finger and 30° in the small finger. Wrist extension was intact, and there was no sensory deficit. We explored the wound and traced the PIN completely, identifying a club-shaped neuroma formation at the proximal cut end of the PIN. Delayed nerve repair was performed with a double-strip cable graft. Hand surgeons should be aware of the probable PIN injury in certain situations of forearm-penetrating injury and perform proper preoperative physical examination to rule out neurovascular deficits. Careful exploration and immediate repair of severe PIN are mandatory, even in emergency situations.

Incidental Median Nerve Injury in the Hand by a High-Speed Drill

Traumatic injuries of the peripheral nerves can be easily overlooked in the emergency department. In these cases, extensive knowledge of anatomy, a high index of suspicion and correct evaluation of neurological status could maintain the proper diagnosis.

Median nerve injury in the region of the hand is commonly due to glass material. However, extremely rare, other causes of injury, such as pieces of wood, acupuncture needle-fracture bodies, metallic foreign bodies, and migration of K-wires, have been reported. In the current report, a case of median nerve injury in a 35-year-old man treated with a high-speed drill was reported to my knowledge for the first time in the current literature. Early and correct diagnosis for nerve injury is crucial for improved functional outcomes.

[Transfixing wound of the forearm due to implantation of an unusual sharp object: a case report]

Les plaies traumatiques transfixiantes des membres avec corps étranger resté implanté sont rares. L´atteinte du segment antébrachial peut entrainer des lésions tissulaires nécessitant un traitement chirurgical spécialisé. Peu d´études concernant ces cas ont été rapportées, une ablation chirurgicale du corps étranger est indiquée. Nous rapportons le cas d´un patient de 23 ans, victime de violences physiques, présentant une plaie transfixiante par implantation d´un couteau atypique à l´avant-bras. L´examen clinique et radiographique a diagnostiqué des lésions musculaires et neurovasculaires importantes. L´intervention chirurgicale a permis le retrait du couteau et la réparation des lésions. La prise en charge de tels traumatismes doit être faite par une équipe chirurgicale expérimentée afin d´éviter la survenue de lésions iatrogènes.

Radial nerve palsy

As a result of its proximity to the humeral shaft, as well as its long and tortuous course, the radial nerve is the most frequently injured major nerve in the upper limb, with its close proximity to the bone making it vulnerable when fractures occur.Injury is most frequently sustained during humeral fracture and gunshot injuries, but iatrogenic injuries are not unusual following surgical treatment of various other pathologies.Treatment is usually non-operative, but surgery is sometimes necessary, using a variety of often imaginative procedures. Because radial nerve injuries are the least debilitating of the upper limb nerve injuries, results are usually satisfactory.Conservative treatment certainly has a role, and one of the most important aspects of this treatment is to maintain a full passive range of motion in all the affected joints.Surgical treatment is indicated in cases when nerve transection is obvious, as in open injuries or when there is no clinical improvement after a period of conservative treatment. Different techniques are used including direct suture or nerve grafting, vascularised nerve grafts, direct nerve transfer, tendon transfer, functional muscle transfer or the promising, newer treatment of biological therapy. Cite this article: Bumbasirevic M, Palibrk T, Lesic A, Atkinson HDE. Radial nerve palsy. EFORT Open Rev 2016;1:286-294. DOI: 10.1302/2058-5241.1.000028.

A Rare Type of Upper Extremity Injury: Penetrating Injuries Caused by Blunt-edged Items

BACKGROUND

Penetrating upper extremity injury is a common encountered cause of significant loss of labor force and it is generally caused by sharp items. This article presents five rare cases of penetrating hand and forearm injury caused by blunt-edged items in conjunction with a detailed discussion of the mechanism and management of the injury.

METHODS

Five patients with a mean age of 37.6 were treated for upper extremity trauma caused by "blunt-edged items" such as corrugated iron fence, garden wires, iron stick or iron safety fence between 2009 to 2014. All patients were operated under general anesthesia after performing detailed physical examination and x-ray imaging.

RESULTS

The explorative surgery of the affected limbs revealed no nervous or vascular injury. In two patients, partial tear of the muscles bellies of intrinsic hand muscles (opponens pollicis and adductor pollicis); in two patients, partial extensor digitorum communis tendon laceration and in the remaining patient, partial tear of the third annular pulley were the only encountered injuries. The physical examinations performed in the last visit of each patient revealed, complete healing of the affected limb without any functional, vascular or sensorial deficiency in a mean follow-up period of 19.2 months.

CONCLUSIONS

Despite their initial horrible appearance, injuries caused by "blunt-edged items" are quite harmless to the affected limb because they follow weak anatomic spaces of the extremity and cause minimal tissue damage leaving all vascular and nervous structures intact.

Differential diagnosis of finger drop

Finger drop is a useful clinical sign which is easy to elicit. This article presents a logical approach for assessing patients with finger drop and outlines the important causes, and how to differentiate them. Patients with finger drop may present either to orthopedic surgeons or to neurologists, and both specialists should be aware of important diagnoses in their complementary fields.

Posterior interosseous neuropathy: electrodiagnostic evaluation

Electrodiagnostic studies are used to anatomically localize nerve injuries. These tests help differentiate between cervical radiculopathies, brachial plexopathies, and peripheral nerve injuries. They also help to identify or rule out other underlying neurological diseases and disorders. In this case report, a 22-year-old male swimmer presented with left finger extensor weakness following pull-up exercises. Left wrist extension remained intact. Electrodiagnostic testing revealed a severe but incomplete posterior interosseous neuropathy. Magnetic resonance imaging confirmed inflammation of the nerve in the forearm. Posterior interosseous neuropathy is an uncommon but well-studied condition. Typically, this condition presents with weakness in finger and thumb extension with preserved wrist extension as the extensor carpi radialis longus is innervated proximal to the site of nerve compression in most cases. It is important to understand the anatomic course and distribution of the radial nerve in order to make an accurate diagnosis. Once the anatomy is understood, electrodiagnostic testing may be used to identify the location of nerve injury and exclude other disorders.