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Transient radial nerve palsy related to intraoperative right lateral positioning for Kuntscher intramedullary nail insertion.

ABSTRACT

This paper reports a rare case of transient radial and axillary nerves palsy related to intraoperative right lateral positioning for Kuntscher intramedullary nail insertion that caused postural cervical traction. Although injuries can occur at any time, injuries to the brachial plexus are generally due to traction or stretch mechanisms, such as when the head and the shoulders of a motorcycle driver are forced in divergent directions during a fall. Neuropraxia, in which the nerve has been damaged but not torn, is the most common type of brachial plexus injury.

The patient had neuropraxia, which manifested as loss of sensation and motor function in the right upper limb immediately after recovery from general anesthesia. He was treated using physiotherapy modality, comprising trans cutaneous electrical nerve stimulation (TENS) and proprioceptive neuromuscular facilitation (PNF) coupled with progressive strengthening exercises. He fully recovered after four weeks of progressive physiotherapy.

This case report suggested that intraoperative positioning during Kuntscher intramedullary nail insertion can be complicated by traction injury. It was therefore suggested that adequate care must be taken during such procedures, especially when it is associated with manipulation. The paper also demonstrated the role of timely physiotherapy in the restoration of normal motor function.

Key words: intraoperative positioning, cervical traction, radial nerve palsy, physiotherapy

INTRODUCTION

The radial nerve arises from the upper root of the brachial plexus which is a complex web of large nerves that exit from the spinal cord in the neck, and direct the movement and sensation of the upper limbs. The nerves divide and join repeatedly before terminating in several peripheral nerves that branch out to supply the muscles of the shoulder and upper limbs. Each nerve root has contributions to several peripheral nerves and vice-versa, and that contributes to highly variable patterns of injury. (1) The plexus is located immediately above and below the clavicle, or collarbone, and the peripheral nerves begin approximately at the level of the shoulder joint. The brachial plexus is usually injured by traction, or stretch mechanism, such as when the head and shoulders of a motorcyclist are forced in divergent directions in a fall. (2) The brachial plexus is the peripheral nerve most commonly injured by malpositioning during operations. (3) The radial nerve has been implicated in traction injuries following a fall over the shoulder, use of axillary crutches, Saturday night palsy in drunks, prolonged use of tourniquets and mid-shaft humeral fractures. (4) The extent of spontaneous nerve recovery is variable, although, the vast majority of patients recover following non-operative treatment. Frequent thorough examination following injury is mandatory in order to document signs of nerve recovery. In addition, imaging or electro-diagnostic tests are often required. We report a rare form of transient upper brachial plexus injury involving both the radial and axillary nerves following intra-operative right lateral positioning for Kuntscher intramedullary nail insertion.

CASE REPORT

FO, a 36-year-old grocery store manager, was involved in a motorcycle accident one hour prior to presentation in our casualty unit. His complaint included swelling in the left thigh, pain, and loss of lower limb function. He also had low back pain. There was no external bleeding and no loss of consciousness.

EXAMINATION

The patient's pre-accident weight was approximately 80kg and his height was 1.72m. The body mass index (BMI) was therefore estimated at 27kgm (2). At presentation, he was fully conscious and well oriented in place and time; there was no pallor or jaundice. He was haemodynamically stable with a blood pressure of 120/80mmHg, pulse 82 beats/minute, temperature 37[degrees]C, and respiration 22 cycles per minute. There was no evidence of internal or external haemorrhage. There was swelling and tenderness in the left thigh and inability to lift the left lower limb. The dorsalis pedis artery was palpable and there was full volume bilaterally. The patient also experienced tenderness at the level of the second lumbar vertebra. Motor and sensory functions of all peripheral nerves were intact in both upper limbs and in the right lower limb.

INVESTIGATION

Packed cell volume was 32%. Plain radiograph demonstrated a left mid-shaft femoral fracture, with short oblique and butterfly fragments. There was also compression fracture of the 2nd lumbar vertebra, with 25% loss of height.

TREATMENT

Operative treatment was offered using a Kuntscher intramedullary nail for the stabilization of the left femoral fracture, whereas the vertebra fracture was treated non-operatively.

Operative procedure

During the operative session, the patient was anaesthetized using general anaesthesia and endotracheal intubation. The position was right lateral. This position gives good exposure of the operation site. The patient was therefore placed in the right lateral position throughout this period.

Immediate post-operation

The primary operative procedure of inserting a Kuntscher intramedullary nail was satisfactory. However, patient could not extend the right wrist joint (wrists drop). There was also inability to extend the metacarpophalangeal joints. In addition, there was associated loss of sensation over a well-circumscribed patch on the right lateral deltoid, belly of the brachioradialis and the web between the dorsum of the right thumb and the right index around the anatomic snuffbox. The general muscle power grade for the shoulder muscles and elbow flexors was 2. The power grade for the wrist flexors and wrist extensors was also 2. The patient was diagnosed as having transient radial and axillary nerves palsy due to intraoperative malpositioning.

TREATMENT OF TRANSIENT NERVE PALSY

The physiotherapy unit was invited to manage the radial nerve palsy. Treatment included functional electrical stimulation using the motoric function of a Body Clock transcutaneous electrical nerve simulation (TENS) machine (Body Clock Health Care Ltd. South Woodford, London), proprioceptive neuromuscular facilitation (PNF), auto-assisted strengthening active exercises, and manually-resisted exercises. The patient was treated and reviewed three times a week. After 4 weeks of management, the patient had recovered significantly from his neuropraxia and was able to pull, eat and write with the right hand; normal sensation had also been restored to the 'anaesthetized' areas.

DISCUSSION

A brachial plexus injury can have a devastating effect on upper limb function. The brachial plexus is generally injured by traction or stretch mechanism, such as when the head and shoulders of a motorcyclist are forced in divergent directions in a fall. (2) The common mechanism for these injuries is violent distraction of the entire forequarter from the rest of the body. This usually results from a motorcycle accident or a high-speed motor vehicle accident. A fall from a significant height may also result in brachial plexus injury. Birth trauma has also been implicated in the pediatric age group, especially during childbirth.

The radial nerve has been implicated in traction injury following a fall over the shoulder, use of axillary crutches in thin elderly patients (crutch palsy), (4) in alcoholics or drunks who fall into a stupor with the arm dangling over the back of a chair (Saturday night palsy), prolonged use of tourniquets and mid-shaft humeral fractures.

The right lateral position in which the patient was placed is the ideal position to achieve good exposure of the operating site. Theoretically, it is possible to cause a traction injury, especially if in this position there would be manipulation. (3,5-7) However, no previous case of radial nerve traction injury due to this type of intraoperative positioning during Kuntscher intramedullary nail insertion has been reported in the literature. Frequent and thorough examination following injury is mandatory to document signs of nerve recovery, and additional imaging or electro-diagnostic tests are often required. Some brachial plexus injuries may heal without treatment. Treatment when necessary, however, includes physical therapy and occupational therapy and, in some cases, surgery.

In 1999, Leffert (8) emphasized that the position of the arm at the time of injury affects the levels involved. When the arm is abducted, the force is directed in line with C7. An upper plexus injury usually predominates if the arm is at the side because the first rib acts as a fulcrum to direct the traction forces preferentially in line with the upper plexus. (8) The traction forces can result in preganglionic or postganglionic injuries. Preganglionic injuries refer to dural and arachnoid lesions proximal to the neurons in the spinal ganglion. These lesions do not cause wallerian degeneration or neuroma formation because the axons remain in continuity with the neuron in the spinal ganglion. Postganglionic lesions are defined as lesions distal to the spinal ganglion and are physiologically similar to other peripheral nerve injuries.

The prognosis of brachial plexus injury is highly variable. It depends not only on the nature and site of the injury but also on the age of the patient. In our report, the patient's age of 36 years was favorable. For avulsion and rupture injuries there is no potential for recovery unless timely surgical reconnecting is done. For neuroma and neuropraxia injuries, the potential for recovery varies. Most patients with neuropraxia injuries recover spontaneously with a 90-100% return of function. Timely physiotherapy is, however, very beneficial. (9) Electrical stimulation retards the rate of atrophy of the involved muscles. (10) It also promotes the restoration of normal nerve conduction by improving local and regional circulation to facilitate healing. Proprioceptive neuromuscular facilitation, together with progressive strengthening exercises, restores muscle strength and functional use of the limb. (11)

In conclusion, this paper has indicated that the intraoperative lateral position during Kuntscher intramedullary nail insertion can be complicated by brachial plexus traction injury. Adequate care must, therefore, be taken to obviate this possibility during procedures that require manipulation. The paper also demonstrated the positive role of timely physiotherapy in the restoration of normal function in transient radial nerve palsy resulting from intraoperative right lateral positioning for Kuntscher intramedullary nail insertion.

REFERENCES

(1.) Wolfe SW. Adult and Pediatric Brachial Plexus Injuries. http:/orthopaedics.hss.edu/services/ hadn/brachial-plexus/index; asp June 2nd 2004

(2.) Steinmann, SP, Moran EA. Axillary nerve injury: Diagnosis and treatment. J Am Acad Orthop Surg 2001; 9(5): 328-335.

(3.) Liu ST, Huang SJ, Chu YH, Wong CS, Wu CT, Ho ST. Brachial plexus injury during surgery-report of two cases. Acta Anaesthesiol Sin 1997; 35(3): 181-185.

(4.) Raikin S, Froimoson MI. Bilateral brachial plexus compressive neuropathy (crutch palsy). J Orthop Trauma 1997; 11(2): 136-138.

(5.) Abe S, Miura Y, Amagasa S, Kato A, Horikawa H. A case of postoperative palsy of the brachial plexus and facial nerve caused by use of a cervical collar during lung surgery. Masui 2002; 51(8): 892-895.

(6.) Mitterschiffthaler G, Theiner A, Posch G, Jager-Lackner E, Fuith LC. Lesion of the brachial plexus, caused by wrong positioning during surgery. Anasth Intesivther Notfallmed 1987; 22(4): 177-180.

(7.) Cooper DE, Jenkins RS, Bready L, Rockwood CA Jr. The prevention of injuries of the brachial plexus secondary to malpositioning of the patient during surgery. Clin Orthop 1988; (228): 33-41.

(8.) Leffert RD. Green's Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone; 1999: 1557-1587.

(9.) Olaogun MOB. Case report on socio-economic and behavioural results of late physiotherapy in Nigeria. J Nig Soc Physio 1992; 11(2): 21-23.

(10.) Low J and Reed A. Electrotherapy Explained, Principles and Practice, 3rd ed. Oxford: Butterworth Heinemann. 2000: 54-55.

(11.) Gardiner MD. Principles of Exercise Therapy. London, G. Bells and Sons, 1976.

IKEM IC, B.M. B.Ch., FMCS (Orth.) Nig., FICS

Department of Orthopaedic Surgery and Traumatology, College of Health Sciences, Obafemi Awolowo University, Ile

Ife, Osun State, Nigeria

OLAOGUN MOB, MS, FNSP

Department of Medical Rehabilitation, College of Health Sciences, Obafemi

Awolowo University, Ile Ife, Osun State,

Nigeria

OBEMBE AO, B.Sc (PT), MNSP

Obafemi Awolowo University, Ile Ife, Osun State, Nigeria

Correspondence: IC Ikem, Department of Orthopaedic Surgery and Traumatology, College of Health Sciences, Obafemi Awolowo University Ile Ife, Osun State, Nigeria * E-mail: innoikem@oauife.edu.ng
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Author:Ikem, I.C.; Olaogun, M.O.B.; Obembe, A.O.
Publication:Journal of the Nigeria Society of Physiotherapy
Geographic Code:6NIGR
Date:Jan 1, 2005
Words:1942
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